Page 1

Volume XXV, No. 12

March 2012

The Independent Medical Business Newspaper

Stepping up patient safety Health care as a team sport By Karyn D. Baum, MD, MSEd, and Albertine S. Beard, MD

A

s the operation draws to a close, Nancy, a third-year medical student, is confused. She is sure there is one more sponge yet to be accounted for. But should she speak up? Her attending is well respected and a good physician—surely he must realize? Nancy wants to become a surgeon, and does not want to risk the anger of the chief surgeon by publicly pointing out a mistake. After all, she needs a letter from him if her dreams of a urology residency are ever to become reality. Many of us have been Nancy at some point in our careers. The Institute of Medicine’s 1999 publication “To Err is Human” brought into the public eye the gravity of the safety issues in health care, with estimates of between 44,000 and 98,000 deaths per year in the United States

G

“Medical care” and “health care”

important to everyone in the community, so the difference is important to appreciate. choose: The MerriamAn avoidable conflict • A doctor/clinic with Webster dictionary better health care By E. John English, MD defines “health” as the quality rankings OR state of • A doctor/clinic with being free from illness or better medical care quality rankings injury. It defines “medicine” as These two ratings presently are lumped the science or practice of diagtogether as “health care.” Health care is a nosis, treatment, and prevenmajor contributor to any individual’s welltion of disease.” What’s espebeing, but it is not the only part. Medical cially relevant is that, begincare is also a major contributor to a long ning in the mid-1980s, what life. This article examines the distinction used to be known as “medical between “health care” and “medical care” care” was supplanted by the and questions a measuring system that iven only one choice, what would you

highlights one over the other under one “quality” banner. Both types of care are

CARE to page 10

SAFETY to page 12

IN THIS ISSUE: Community Caregivers Page 20


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CONTENTS

MARCH 2012 Volume XXV, No. 12

FEATURES

MINNESOTA HEALTH CARE ROUNDTABLE “Medical care” and “health care” An avoidable conflict

1

By E. John English, MD

Stepping up patient safety Health care as a team sport

1 T H I R T Y- S E V E N T H

SESSION

By Karyn D. Baum, MD, MSEd, and Albertine S. Beard, MD

Community Caregivers 2012 Making a difference in Minnesota and the world

20

By Scott Wooldridge

DEPARTMENTS CAPSULES

4

MEDICUS

7

INTERVIEW

8 Larry Shellito Minnesota Department of Veterans Affairs

SCREENING GUIDELINES Screening mammography

18

By Joseph H. Tashjian, MD

PSYCHIATRY A breakthrough in treating depression

Controlling the cost of care Thursday, April 19, 2012 28

By Abraham Verjovsky, MD

PROFESSIONAL UPDATE: RADIOLOGY Spotlight on imaging 14

TRANSPLANTATION From fiction to reality in half a century

30

By William D. Payne, MD

By Scott R. Schultz, MD

ALLIED PROFESSIONS Physician assistants

SCREENING GUIDELINES The prostate cancer dilemma

By Pamela M. Dean, MBA

Specialty pharmacy

34

16

By Thomas J. Stormont, MD

The Independent Medical Business Newspaper

1:00 – 4:00 PM • Duluth Room Downtown Mpls. Hilton and Towers

Background and focus: Medications treating chronic and/or life-threatening diseases are frequently new products, which are often more expensive than generic or older, branded products that treat similar conditions. The term specialty pharmacy has come to be associated with these medications. Exponents claim the new technology improves quality of life and lowers the cost of care by reducing hospitalizations. Opponents claim the higher per-dose cost spread over larger populations does not justify the expense.

The cost of research, both failed and successful, is reflected in product pricing. Current federal guidelines allow generic equivalents marketplace access based on the patent date, not the release date, of a product. This considerably narrows the window in which costs of advances may be recovered. A further complicating dynamic involves the payers. Physician reimbursement policies sometimes reward utilizing lower-cost “proven” products and cast those prescribing highercost products as “over-utilizers,” placing them in lower-tiered categories of reimbursement and patient access. Objectives: We will discuss the issues that guide the early adoption of new pharmaceutical therapies and how they relate to medical devices. We will examine the role of pharmacy benefit management in dealing with the costs of specialty pharmacy. We will explore whether it is penny-wise but pound-foolish to restrict access to new therapies and what level of communication within the industry is necessary to address these problems. With the baby boomers reaching retirement age, more people than ever will be taking prescription medications. As new products come down the development pipeline, costs and benefits will continue to escalate. We will provide specific examples of how specialty pharmacy is at the forefront of the battle to control the cost of care.

www.mppub.com PUBLISHER Mike Starnes mstarnes@mppub.com EDITOR Donna Ahrens dahrens@mppub.com ASSOCIATE EDITOR Janet Cass jcass@mppub.com ASSISTANT EDITOR Scott Wooldridge swooldridge@mppub.com ART DIRECTOR Elaine Sarkela esarkela@mppub.com

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MARCH 2012 MINNESOTA PHYSICIAN

3


CAPSULES

WestHealth to Open Stand-alone ED WestHealth, an outpatient medical center owned by Allina Hospitals and Clinics, will open a stand-alone emergency department by the end of this year, officials announced recently. The new facility will be staffed by emergency medicine physicians from Abbott Northwestern and is part of an ongoing expansion at the site in Plymouth. The emergency department will be an 18,000square-foot building adjacent and attached to the 180,000square-foot campus. “This will be the outpatient health care campus of the future and another step toward Allina’s commitment to achieving the Triple Aim of lower costs, higher quality, and improved patient experience,” says Ben BacheWiig, MD, president of Abbott Northwestern Hospital. Officials say the WestHealth campus is designed to meet a wide spectrum of needs at a location convenient to patents in the west metro area. The facility

currently offers primary care, pharmacy, outpatient surgery, imaging, specialty care, and urgent care. Future plans for the site include a transitional care unit to provide care in a lower cost setting than a traditional hospital.

Allina Announces Name Change Allina Hospitals and Clinics is changing its name to Allina Health, officials with the Minneapolis-based health system said recently. The name change is being phased in slowly, but new signage will start making an appearance this spring, officials say. According to David Kanihan, spokesman for the health system, the change has been under discussion for some time and reflects changes going on in health care delivery in general. “Our name has been Allina Hospitals and Clinics, and while hospitals and clinics will continue to be a core part of what we do, our focus needs to be broader than that,” Kanihan

says. “If we’re going to be in a position to be charged with overall health of a community, we have to be involved with people beyond what happens in a hospital or clinic.” The move reflects new approaches to health care delivery that emphasize health management, integrated approaches to care, and “upstream” preventive measures. Kanihan notes that health care reform efforts put a great emphasis on prevention and community health, and says the name change will underscore those strategies. “Our measure of success has been how many admissions to hospitals we’ve been able to generate,” he notes. “Our measure of success in the future may be the complete opposite.” He says the system will continue to sharpen its focus on wellness, prevention, chronic disease management, and end-of-life care. The name change got its first public debut at a speech in February at the University of Minnesota by Ken Paulsen, Allina’s CEO. Paulsen was

quoted by the Minneapolis Star Tribune as saying, “We’re never going to build another hospital,” and Kanihan says the statement reflects the organization’s new focus. “Hospitals are important, but we need to think beyond hospitals,” Kanihan says. “We have 11 really good hospitals and they will continue to be very important to what we do, but they won’t be the only thing we do.”

HealthPartners to Open Southside Clinic HealthPartners has announced plans to open a primary care clinic with urgent care services in South Minneapolis later this year. The 7,800-square-foot clinic, called HealthPartners Clinic in South Minneapolis, will offer a range of services, including family practice, obgyn, chiropractic, laboratory, and imaging services. The clinic will also feature an evening and weekend urgent care clinic. It will be located on Chicago Avenue between 47th and 48th

In person

Inbox

When changes in the local health care landscape promised a major influx of new UCare members coming through metro-area clinics and hospitals, we made sure those providers were prepared. In a span of just two weeks, May Ly was among the UCare staff that personally visited 449 unique health care locations to offer a heads-up and explain the impacts. Because being responsive to our partners’ needs isn’t just talk—it’s what we mean by health care that starts with you.

| provider assistance: 1-888-531-1493 | ucare.org/providers |

4

MINNESOTA PHYSICIAN MARCH 2012

©2012, UCare.


Streets in an existing retail space, with five physicians expected to practice at the facility. “We’re looking forward to partnering with the local community, including neighborhood groups, schools, and businesses,” says Mary Brainerd, HealthPartners president and CEO. “Their involvement, engagement, and support is vital throughout the planning and design process. We want the clinic to reflect the character of the neighborhood it serves.”

ACA Changes Physician Reporting Of Drug Company Federal regulators are creating a system to publicly report payments to physicians from drug companies and medical device manufacturers, as a way of increasing the transparency of such arrangements. The Physician Payment Sunshine Act, part of the Affordable Care Act (ACA), would create a national system that mirrors groundbreaking legislation passed by Minnesota lawmakers in 1993. This may lead to the current Minnesota database of physician payments being discontinued. The Minnesota law requires drug companies to report to a state database, compiled by the Minnesota Board of Pharmacy, every time they pay a physician $100 or more in speaking or consulting fees. It also requires drug manufacturers to report gifts given to physicians, such as meals or entertainment outings. The new national regulations would require companies that manufacture pharmaceuticals, medical devices, or biological or medical supply products to track and report payments of $10 or more made to physicians and teaching hospitals. The new rule also requires manufacturers and group purchasing organizations to disclose any financial ties to physicians or their family members. Proponents of the Sunshine Act often cited the Minnesota reporting law, first implemented in 1997, as a model for providing transparency in physician payments from drug companies and device manufacturers.

According to Cody Wiberg, executive director of the Minnesota Board of Pharmacy, his group monitors both nonmonetary gifts to practitioners as well as payments for things such as consulting, research, and medical education. The Minnesota database on gifts will continue, Wiberg says, but the new federal regulations preempt state databases, so his organization will be required to stop collecting data on payments to physicians from drug manufacturers. The Minnesota system, though not the only state database, did encourage a change in the way physicians and drug companies approach payments, Wiberg says. “I think they’re taking reporting far more seriously than they used to,” he says. “Physicians and health institutions are more careful about accepting research grants, and pharmaceutical manufacturers are a little more careful about how they give them.”

Accretive Health License Suspended By Commerce A Chicago-based debt collection agency is getting additional scrutiny from the state of Minnesota. Accretive Health, which was recently sued by Minnesota Attorney General Lori Swanson over lost patient medical records, is under investigation from the state Department of Commerce, officials announced on February 3rd. Swanson’s suit, filed in January, called on Accretive to fully disclose what information it gathers on patients in Minnesota, where the company works with Fairview Health Services and North Memorial Health System. In July 2011, an Accretive employee lost sensitive information on 23,500 patients when a laptop was stolen from a car. In the new move by the Commerce Department, Commissioner Mike Rothman has suspended Accretive’s license to do collections in Minnesota until the company is in compliance with state law. Rothman says his agency is CAPSULES to page 6

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MARCH 2012

MINNESOTA PHYSICIAN

5


CAPSULES

Capsules from page 5 investigating whether Accretive deceived debtors, allowed unregistered employees to act as debt collectors, and disguised its role as a collection agency. “These allegations represent a troubling disregard for our debt collection laws,” Rothman says. “We are investigating this matter thoroughly, which will require the company’s utmost cooperation.”

Gundersen Lutheran To Market HMO In Minnesota A new health plan was certified for the Minnesota market in February, as the Minnesota Department of Health (MDH) announced Gundersen Lutheran Health Plan Minnesota would operate an HMO in four counties. The health plan, based in Onalaska, Wis., will do business in Fillmore, Houston, Olmsted, and Winona counties in southeastern Minnesota. The Gundersen Lutheran health plan, which has 90,000 members

in Wisconsin and Iowa, is the first to be certified in Minnesota since 1998. The state certified the plan after a Minnesota Department of Commerce analysis of Gundersen’s financial fitness. As with all health plans marketed in Minnesota, the new HMO will operate as a nonprofit. According to Allan Baumgarten, an analyst who regularly issues reports on the Minnesota HMO market, the three main areas of HMO enrollment in southeastern Minnesota are senior plans, Medicaid plans, and employer-based plans—with the last category seeing a significant decline in numbers during the past 10 years. Baumgarten notes that Gundersen serves similar markets in western Wisconsin. “They could probably position themselves effectively in all three market segments, because they have a significant physician and hospital presence in the region,” he says. “I think they could leverage that to offer competitive prices, so the opportunities are potentially good for them.”

2012 CME Courses

There is also the possibility that the state will expand its competitive bidding process for Medicaid plans to cover areas such as southeastern Minnesota, Baumgarten says. “This could be an opportune time for a new entrant like Gundersen to make a proposal,” he says.

Stratis Expands Palliative Care Stratis Health has announced that it has chosen seven rural Minnesota communities to work with in improving palliative care. The Rural Palliative Care Community Development Project will involve more than 40 organizations in an effort to establish or strengthen palliative care in rural areas of the state. The announcement follows earlier programs launched by Stratis to promote palliative care in Minnesota. To date, 23 Minnesota communities have been part of Stratis’ palliative care initiatives. Palliative care helps patients manage chronic disease and

other serious and advanced illness. The approach centers on relieving suffering and improving quality of life for patients and their families. “With chronic diseases as a leading cause of death and disability in Minnesota, our health care services need to evolve to provide appropriate care. We need treatment plans tailored to each patient’s goals and new delivery methods that cross multiple health care settings,” said Jennifer Lundblad, PhD, MBA, president and CEO, Stratis Health. “By fostering palliative care in rural communities we hope to decrease the number of patients having to leave their home community to receive this patient-centered care.” The organizations chosen for this initiative are Community Memorial Hospital Association in Cloquet; Johnson Memorial Homecare in Dawson; Kenyon Senior Living; Madelia Community Hospital; Madison Hospitals Home Care Agency; Mercy Hospital in Moose Lake; and Essentia Health East Range Hospice in Virginia.

www.cmecourses.umn.edu

(All courses in the Twin Cities unless noted)

Pediatric Dermatology Progress & Practices May 18, 2012

SPRING COURSES Lillehei Symposium April 5-6, 2012

Bariatric Education Days May 23-24, 2012

Cardiac Arrhythmias April 13, 2012 Integrating Behavioral Health into the Health Care Home April 13, 2012 ICU Team Training April 23-25, 2012 NCCIDSA Annual Meeting April 28, 2012 Care Across the Continuum May 11, 2012 Global Health Training May 14-27, 2012

Workshops in Clinical Hypnosis May 31-June 2, 2012 Trauma, Critical Care & Acute Care Surgery June 7-8, 2012 Topics & Advances in Pediatrics June 7-8, 2012

FALL COURSES Pediatric Hypnosis Training (NPHTI) September 20-22, 2012

ONLINE COURSES (CME credit available) For more information: www.cme.umn.edu/online U Fetal Alcohol Spectrum Disorders (FASD) U Global Health (7 Modules), to include: - Intro to Health Care for Immigrant and Refugee Populations - Parasitic Infections - Travel Medicine

Twin Cities Sports Medicine October 5-6, 2012 Practical Dermatology, Duluth, MN October 26-27, 2012 Internal Medicine Review October, 2012 Geriatric Trauma November 29-30, 2012

Office of Continuing Medical Education 612-626-7600 or 1-800-776-8636 email: cme@umn.edu

Promoting a lifetime of outstanding professional practice

6

MINNESOTA PHYSICIAN

MARCH 2012


MEDICUS

REQUEST FOR NOMINATIONS

Minneso

In our August 2012 edition, Minnesota Physician will profile 100 of our state’s most influential health care leaders. In a format featuring photos, bios and quotes, we will highlight the men and women most responsible for making Minnesota a global model for health care delivery.

s Most In ’ a t

These individuals will represent every aspect of the industry —physicians, business executives, political leaders, policy analysts, etc.

ential flu

Tim Zager, MD, began his new role as president of Essentia Health-Duluth Clinic in December. Zager has served in many leadership roles at Essentia Health, most recently as chief of the Medical Specialties Division, a position he had held since 2004. A board-certified pediatrician at Essentia Health–Duluth Clinic since 1982, Zager is also a clinical assistant professor at the University of Minnesota, Tim Zager, MD Duluth, School of Medicine and has won several teaching awards from the Duluth Family Practice Residency. Two physicians were recognized for their service to the community at the annual meeting of Lakeview Hospital medical staff in December. Thomas Stormont, MD, was recognized for his long commitment to Lakeview Hospital, where Thomas Stormont, MD he continues to serve as Surgery Department chair. He is a board-certified urologist who completed his residency at Mayo Clinic. Andrew Dorwart, MD, was recognized for leadership commitment to Lakeview Health System. He has held many leadership positions in the past and currently serves as president of Stillwater Medical Group. Dorwart is a board-certified internal medicine physician who completed his residency at Hennepin County Medical Center. This is the 16th year that Lakeview Hospital has awarded physician recognition awards, which are given annually by physician peers to recognize fellow physicians for their overall distinguished service to LakeAndrew Dorwart, MD view Hospital, its patients, and the community. Aspen Medical Group has recently added three physicians at its clinics. Kang Xiaaj, MD, family medicine, will practice at the East Lake Street Clinic. Xiaaj earned her degree at the University of Minnesota Medical School and completed her residency at Regions Hospital. Josaleen Davis, MD, internal medicine and geriatrics, will see patients at the Hopkins clinic. Davis earned her degree at the University of Minnesota Medical School and completed her residency at Maine Medical Center. Heather Jensen, DPM, MHA, will see patients at the Bloomington and Hopkins clinics and the Specialty Center in St. Paul. Jensen earned her degree at Des Moines (Ia.) University’s College of Podiatric Medicine and Surgery. Jennifer Johnson Martinelli, MD, has joined Essentia Health’s Duluth Clinic urgent care department. She most recently worked at St. Luke’s hospital in Duluth. Martinelli received her medical diploma from St. George’s University School of Medicine in Big Shore, N.Y., and completed her internship at St. Paul-Ramsey Medical Center and her residency at HealthPartners Institute for Medical Education in St. Paul. Chad Pedersen, MD, an internal medicine physician, has joined the Winona Health medical staff as a hospitalist. Pedersen received his medical degree at the University of North Dakota in Grand Forks and completed his residency at Gundersen Lutheran Medical System in La Crosse, Wis., where he served as chief resident. Craig Strauss, MD, MPH Craig Strauss, MD, MPH, has joined the Minneapolis Heart Institute and will see patients in Alexandria, Cambridge, Monticello, and Plymouth. Strauss has worked on research projects with the Minneapolis Heart Institute since 2005, including participating in its acute aortic dissection program. Strauss received his medical degree at Dartmouth Medical School and also earned a master’s of public health degree at the Dartmouth Institute for Health Policy and Clinical Practice. He completed his residency at Abbott Northwestern Hospital, where he was chief resident, and performed a fellowship at the University of Minnesota.

We invite you, our readers, to particiHealth Care Leaders pate in this recognition process. If you know anyone within your organization you feel should be considered, please fill out the form below and return it by mail, fax or email prior to May 25, 2012. We welcome your input and participation in making this list as comprehensive and meaningful as possible.

COMPLETE AND RETURN THE FORM BELOW Name: ____________________________________________________________ Business Affiliation:__________________________________________________ Phone/Fax: ________________________________________________________ Notable Accomplishments: ___________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Your Name and Phone # (Optional & Confidential): _____________________________ __________________________________________________________________ __________________________________________________________________ Minnesota Physician Publishing, Inc. 2812 East 26th Street • Minneapolis, MN 55406 Phone 612-728-8600 • Fax 612-728-8601 e-mail comments@mppub.com

MARCH 2012

MINNESOTA PHYSICIAN

7


INTERVIEW

Caring for the returning veteran ■ Please tell us about the size and scope of the

VA in Minnesota.

Maj. Gen. Larry Shellito Minnesota Department of Veteran Affairs Larry Shellito was appointed by Gov. Mark Dayton as the Commissioner of the Minnesota Department of Veterans Affairs. A retired major general with the Minnesota National Guard, he led the fifth-largest state Guard for seven years, overseeing 14,000 members in 63 facilities across the state. As commissioner, Shellito’s responsibilities include oversight of Minnesota’s five Veterans Homes, as well as the MDVA’s claims, outreach, benefits, higher education program, and mental health services. Shellito had a 42-year career in the military, including serving in Vietnam. He has been awarded the Distinguished Service Medal, Legion of Merit, Bronze Star, and Combat Infantryman’s Badge.

Commissioner?

The Veterans Administration (VA) is the federal My responsibility is to make sure that those CVSOs side, and they are the ones that do a lot of the are trained. I have two elements under my direct medical care. The two main facilities in Minnesota supervision. I have a deputy commissioner in are the Minneapolis VA Medical Center, here in charge of the five veterans’ homes and I have Minneapolis, and the St. Cloud Medical Center. another deputy commissioner who is responsible There’s also a medical center in Sioux Falls, S.D., for our programs and services. The program servicthat covers part of our state’s southwest corner, and es are programs for traumatic brain injury, counthe Fargo, N.D., medical center that catches some seling, financial assistance, those types of things. of our northwest veterans. ■ As Commissioner, what are your goals for the St. Cloud has a community-based outreach MDVA in Minnesota in the coming years? clinic (CBOC). There are CBOC locations in Montevideo, Brainerd, and Alexandria. There’s also There are 380,000 veterans in the state of Minneone in Fergus Falls, but that’s part of Fargo. A lot sota. According to the VA, 72 percent of them don’t of our veterans just need that checkup and some of receive any benefits from the government. My goal their medications and so forth, so they can go is to do outreach, to find the veterans, make them there without having to travel a great distance. aware of what opportunities they have available to That’s all on the federal side. them, and then work with them to help them get Now with the Minnesota Department of Veterthe services that they need. ans Affairs (MDVA), on the state side, we have five We have been at war for over 10 years. We veterans’ homes. They’re like nursing homes, with have created a lot of veterans. These veterans are residential living. They are located in Minneapolis, coming back with different issues. In the Vietnam which is our largest, and in Hastings, Luverne, War, there were over 53,000 killed in action. The Fergus Falls, and Silver Bay. number with the new conflicts is around 5,000. In addition, every county has County Veteran What makes up that difference is the medical comService Officers (CVSOs). munity. The medical responThey are paid for by the siveness in Afghanistan and The mantra that we county but coordinated by Iraq is absolutely phenomeour state office. Their job is are using is, “Bring them nal. When these veterans to seek out veterans that live come back, we’re going to all the way home.” in their community and eduhave them for the next 40 cate them as to what benefits years. are available. With older veterans, they would eduAgain, as with most wars, there’ll be a lot of cate them about our Veterans Homes. Or, if they them that will be sent home, and then all of a sudhave medical needs and medications, we will actuden the memories, the flashbacks, the undiagnosed ally transport them to the federal medical centers PTSD will be there, and that’s where our focus is in St. Cloud or Minneapolis. going to be. Our goal, the mantra that we are using They’re the people that go out into the veteran is, “Bring them all the way home,” which means community and say, “All right, here’s what you not only physically but also mentally and emotionneed.” If it’s to get your medicines and check your ally, and get them back into productive society. blood pressure, we’ll take you to the nearest com■ You mention that many veterans don’t utilize VA munity-based outreach center. A veteran’s physiservices—what can be done about that? cian might discover something that’s pretty serious, so the CVSO would help to get you to the next One of the issues we have is that on hospital or higher level, which would be the medical center. clinic admissions forms, no one ever asks, “Are you The CVSO oversees a variety of benefits for our a veteran?” Just add another question about being veterans. But if veterans don’t ask for it, they’re not a veteran. That could create additional opportunigoing to get it. Most veterans don’t know how to ties. Especially with the older veterans, I see this as ask for it. being extremely important. There are a lot of people who don’t have health insurance. A physician ■ How do these different facilities interact? could say, “Here’s another option you might want Let’s pick Alexandria as an example. They have a to think about—call your CVSO.” CBOC. They might say, “This is a little bigger med■ With the economy the way it is, a lot of people ical issue than we can care for. So we’re going to fall off the employer-based insurance plans, so transport you now to St. Cloud.” St. Cloud might what you’re saying is that this would be another decide the patient should go to the next higher place veterans could go. level. The highest level of care would then be at the Minneapolis medical center. With that concept of triage, my personal goal is to have care delivered at the most appropriate level. That’s the most cost effective.

8

■ What are your responsibilities as MDVA

MINNESOTA PHYSICIAN MARCH 2012

Correct. I just had a carotid artery worked on. That’s about a $40,000 bill, and that would devastate most people in the state, especially if they’re on


■ Traumatic brain injuries (TBI) have gotten

a retirement income or they’re not fully employed. A primary care physician could tell someone in that situation about their CVSO. We also have a website, MinnesotaVeteran .org, for information. Our goal is to be continually educating veterans on their benefits. There are so many things that are changing on the federal level; it’s very dynamic. We’re talking to people, we’ve got our website, we’ve got CVSO training, all those things, but in a way, the enemy is Minnesota pride: That 72 percent basically say, “I’m okay, take care of my buddy, take care of my friend.”

a lot of attention since the Iraq War. How is the VA addressing this health issue? On the federal side, there are specialists at the Minneapolis VA Center. As I said, it is noted nationwide. They are one of the four polytrauma centers in the United States. What we are doing as a state is to have a member of our MDVA staff working with the Department of Human Services to address TBI here in Minnesota. We are working very actively on the state level to identify people with TBI and then direct them to the treatment that they need, whether it be local, state, or federal.

■ Women are playing a larger role in our

armed forces; what kind of challenges do their health care needs present?

■ What can you tell us about how the

First of all, you are absolutely correct. Women are playing a larger and growing role in the military. They have proven themselves to be absolutely outstanding. One of the early complaints, on the federal level in particular, is that all of the medical centers were male-oriented—the exam rooms, the bathrooms, etc. That is continually being addressed because of the number of female veterans. With new construction, those community-based outreach centers, which are relatively new, have facilities and doctors there to take care of women also.

MDVA system is dealing with the mental health needs of veterans? In addition to the federal VA programs, MDVA partnered with Lutheran Social Service and created a program we call CORE, which stands for Case Management, Outreach, Referral, and Education. Basically it’s an outreach, where the state provides funding to enable our veterans to seek professional counseling close to or in their own communities When veterans have mental health issues, their unit commander will get them connected to a trained professional counselor with the CORE program. This program provides essential mental health services to active duty members, veterans,

and family members at no charge. It’s funded by the state and through the Support Our Troops license plate fees. ■ What would you like physicians in

Minnesota to know about the resources that the Minnesota VA provides? I want physicians to know that there are a number of safety net programs for patients who are veterans. Ask patients to identify if they are or are not veterans. If they are veterans, then that makes some other options available. Obviously, first and foremost, physicians should just take good care of all their patients, do the diagnostic, and if they get to the point where there are more things needed, say, “As a veteran, you also have this option to check out.” Physicians don’t need to know all the answers. They just need to know that every county has a CVSO. And if they have a moment during an office visit with a veteran: Just visit with him or her and let that be part of the learning process. We’ve taken a lot of 18-, 19year-old kids and made them grow up pretty dang fast, and they’re struggling. I go back to my same doctor, not just because he’s good, but it’s the relationship, the bond of trust. If the physician can establish a bond of trust with that veteran, that is absolutely essential and critical.

15th Annual ICSI Colloquium on Health Care Transformation May 7–9, 2012 t Minneapolis Convention Center

Engaging Patients, Accelerating Change, Improving Value

Top 10 Reasons Why This ICSI Event Will Support Your Organization’s Health Care Transformation Keynoters 1. Todd Park, Chief Technology Officer, U.S. Health and Human Services 2. Tom Bodenheimer, MD, MPH, FACP, University of California San Francisco

Closing Session 3. Harold Miller, President and CEO, Network for Regional Healthcare Improvement Four Tracks Led by National/Local Experts 4. Leadership & Accountability 5. Quality & Safety 6. Patient Engagement/ Consumer Experience 7. Integrating Behavioral Health/Primary Care (New!)

Pre-Conference Workshops 8. Use of Social Media to Address the Triple Aim 9. Crucial Conversations® 10. Co-creating a Medication Management System for the Triple Aim

MARCH 2012

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MINNESOTA PHYSICIAN

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Care from cover term “health care.” These terms are now used interchangeably; however, they are very different approaches to the same end

point: the patient’s maximum well-being. Interchangeable use causes confusion for doctors, patients, and policy makers— especially when measurements with mandatory public rankings on quality of doctors/clinics are involved.

Differentiating between “health care” and “medical care”

First, let’s focus on the term “health care.” Health care is a population-based approach designed to improve everyone’s well-being. It’s prevention, pure and simple. It is a public

We need to collectively address with our patients—the public—where we physicians really fit into the well-being equation.

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MINNESOTA PHYSICIAN MARCH 2012

health–centered, top-down approach that traditionally has been the responsibility of the state. It is focused on community attainment of proven, general preventive measures; its aim is to prevent all society from illness or injury by instituting broadly accepted guidelines for improvement. Once a particular measure is demonstrated to have broad benefit, almost anyone can promote and promulgate it. Originally, statedirected public health programs addressed such areas as requiring a community to maintain a clean water supply or achieve proper sewage treatment. But as those public health goals have been achieved, health plans have intervened and the “health care” message has become “stop everyone’s smoking, have everyone lose weight, control everyone’s blood pressure, lower everyone’s cholesterol, get everyone to exercise three times a week.” The list goes on … but not on forever. The neat part is that all these preventive recommendations can be written down on just one or two pieces of paper. So it’s not that patients don’t know what they should do; it’s the actual doing it that is the problem. In other words, it is compliance or the lack of it that determines the outcome. Success of the various health care programs is measured by percentages of attainment. The more people do the accepted right thing, the less disease and injury occur. And, importantly,

it’s patients themselves that mainly determine the outcome. Unfortunately, patients—otherwise called people—can be a bit ornery with compliance. For whatever reasons, sometimes they simply don’t comply. Preventive “health care” absolutely works, is absolutely worthwhile, absolutely has great benefit, is absolutely timeconsuming, and, as an aside— absolutely costs a lot (and remember, cost is the issue in health care today). Medical care is completely different. It is an individualbased method to restore, maintain, or improve an individual’s well-being. It is highly personal and is, in fact, usually attained one person at a time. It is a hands-on, bottom-up approach. It is diagnosis- and treatmentcentered. At some point in everyone’s life, it is desired, demanded, and sought out, basically after the preventive measures have failed. Traditionally, medical care has centered on having a good doctor who is proficient in his or her craft. One who has a real-time working knowledge of, say, 20,000 pages of text and can constantly make real-time adjustments to meet changing patient needs. One who identifies medical problems early— and directs proper treatment promptly. One who knows what symptom complex is serious, and what is not. And, of course, one who additionally promotes various health-care preventive measures—but perhaps more in the context of how they pertain to each specific individual’s capabilities. At a bare minimum, “medical care” success should be measured by how well an individual’s desired needs are met, as judged by the patient. Curative “medical care” is absolutely worthwhile, absolutely works, absolutely has great benefit, is absolutely timeconsuming, and, as an aside— absolutely costs a lot (and remember, cost is the issue in health care today). Both “health care” and “medical care” approaches are effective and have true value. Doctors should—and do—combine them to help each individ-


The quality measurement imbalance

In the past three decades, especially in primary care, there has been a continued emphasis on measuring “health care” attainment, with little emphasis on measuring “medical care” success or improvement. Patient satisfaction begins to measure medical care but does not address diagnostic accuracy, efficiency, or ideal treatment. That can be judged only by a doctor’s working peers—not by some outside rating agency. This is the area that really needs to be addressed in the today’s publicly reported ratings reports. This is what the public really wants to glean from a public rating system. The Minnesota 2008 Health Reform Law mandated public reporting of various health care “quality measures” attained by

doctors/clinics, beginning in 2010. This legislation ups the ante for physicians. The public needs to be aware of exactly what type of quality is being measured and publicly reported. The answer right now is, “It’s health care”—which is

The public needs to be aware of exactly what type of quality is being measured and publicly reported. largely under the control of the patients themselves, not the physician. The doctor’s role

As physicians, we first must truly appreciate the distinction between medical care and health care. It then follows that two different types of quality measurements are now needed—one to measure each type of care. We must now insist on the proper labeling for each of these measurements.

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We must insist that present “quality care” be relabeled as “preventive services measurement” or some similar designator, rather than simply being called “quality care measurement.” This latter term is just too broad and confusing to the

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public. Our various physician organizations can be instrumental in this endeavor. And following this truth-inranking move, we need to collectively address with our patients—the public—where we physicians really fit into the well-being equation. Yes, we promote preventive health care: always have, always will. And we should take a portion (but definitely not all) of the responsibility for its attainment. But our real value in the

Telephone Equipment Distribution (TED) Program

ual achieve the goal of maximum well-being. This results in society’s maximum well-being.

system is our understanding and application of a great big bunch of knowledge called medical care. If you’re having a baby, your child gets meningitis, a heart attack begins, your gall bladder gets infected, a bad injury occurs, or if you just can’t find an answer to your condition—you’re feeling punk, and you don’t know why—you need a good medical doctor. That’s what you want a ranking system for. That’s the answer to the lead-in question of this article. And that means a doctor whose measured patients may or may not have chosen to opt out of their child’s immunizations, stop smoking, exercise, take their medication—or whatever. E. John English, MD, was a full-time family practitioner for over 40 years, 35 of which were in Apple Valley, Minn. He is presently semi-retired from practice but serves as chairman of the board of the Midwest Independent Practice Association, an organization of independent medical clinics.

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MINNESOTA PHYSICIAN

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Safety from cover as a result of errors in the very system designed to improve health. The Joint Commission has consistently reported that poor communication is a major factor in almost two-thirds of cases. These reports raised the question: If physicians, despite the finest training and best of intentions, could not keep patients safe, what could be done? Other highly complex, highstakes industries, such as aviation, offered some intriguing solutions. These high-reliability organizations minimized human error and became extraordinarily safe by having several qualities in common, including an obsession with avoiding mistakes, and teams that are adaptive, highly effective, and demonstrate excellent communication. Most importantly, these effective teams did not just happen. They were carefully trained and developed. A group of researchers at Beth Israel Deaconess Hospital in Boston applied many of

TeamSTEPPS is based on more than 25 years of the best available scientific evidence for actively creating effective teams able to deliver safe, consistent results. the team training principles developed for aviation safety to their obstetrics department and saw their adverse event (and lawsuit) rate drop by half. Building on that work, the Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense (DOD) developed TeamSTEPPS. Developing the TeamSTEPPS curriculum

TeamSTEPPS, which stands for Team Strategies and Tools to Enhance Performance and Patient Safety, is based on more than 25 years of the best available scientific evidence for actively creating effective teams able to deliver safe, consistent results. Data were incorporated from aviation, the military, and other high-stakes industries such as nuclear power. Organizational

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psychologists helped design a curriculum to teach these strategies and tools that was tailored to health care providers working in all clinical settings. In late 2006, the curriculum was released for use, free of charge, on the AHRQ website. Through the use of didactics, discussion, exercises, and scenarios, the program teaches specific concrete and usable teamwork skills in four key areas: leadership, communication, mutual support, and situation monitoring. These skills touch on all aspects of medical teamwork, such as effective communication during emergencies, concise and clear briefings and feedback, appropriate assertion during conflict, and support for and awareness of other team members’ actions. They are designed to ensure that a potential error by any individual team member is caught and corrected by the team as a whole. Skills are demonstrated using written, case-based scenarios and videos from a variety of health care specialties in both clinic and hospital settings. The variety of materials allows the course to be customized to the needs of the receiving audience. Clinical simulation is often paired with the curriculum, allowing participants to practice the skills they have learned prior to using them in real clinical situations. In Nancy’s case, training in TeamSTEPPS not only would have fostered a climate in the operating room where speaking up was both encouraged and expected, but also would have taught Nancy how to do so firmly but respectfully, with the ultimate goals of maintaining her relationship with the surgeon while protecting the patient from harm. Though the skills taught during TeamSTEPPS training are not complicated, overcoming old habits and incorporating these skills into daily practice can be challenging. In a recent

The New Yorker article, surgeon Atul Gawande described the importance of coaching for the continued improvement of his professional performance. TeamSTEPPS recognizes the crucial role of coaches in honing individual skills and incorporates sessions on coaching coworkers to continually and effectively use these skills. The curriculum also addresses implementation planning and change management, both of which are crucial for implementation of TeamSTEPPS at the institutional level. The AHRQ website provides the PowerPoint slides, handouts, and facilitator guides for each lesson, as well as a host of supporting material, including the evidence used to develop each section, along with citations, more than 100 additional videos and scenarios, and even a leadership brief to help obtain support from institution management for implementation. Curriculum materials can be reviewed and downloaded, with supplemental materials available for purchase if desired, at http://teamstepps.ahrq.gov/. The website also provides additional information, including implementation stories from institutions around the world, webinars (including transcripts), and a readiness assessment, to assure that the facility is ready to begin this journey. After the release of the TeamSTEPPS program, the AHRQ and the DOD jointly sponsored the national implementation of the TeamSTEPPS initiative. This effort was designed to aid in the dissemination and implementation of TeamSTEPPS nationally. The implementation program offered 2.5-day “train-the-trainer” sessions free of charge at five training resource centers throughout the country. The University of Minnesota was one such center, along with Duke Medical Center, Carilion Clinic, Creighton University, and the University of Washington. Over the past four years, as a result of this program, more than 2,000 master trainers have completed training at the training resource centers, and more than 10,000 health care workers across the country


have undergone TeamSTEPPS training locally at their home organizations. The success of this training and support program has led to the continuation of this effort; information on the current centers (which includes the University of Minnesota) can be found at http://teamstepps .ahrq.gov/. Many organizations have documented improvements resulting from this training. Carilion Clinic in Roanoke, Va., which integrated this system into its pediatric intensive care units, subsequently recorded decreases in medical errors, improved patient satisfaction, and decreased staff turnover. Butler County Health Care Center, a 25-bed critical access hospital in Nebraska, documented improved communication and an improved culture of safety throughout the organization using TeamSTEPPS. Given the success of the initial training efforts, the AHRQ is continuing its support by hosting future additional train-the-trainer workshops and continuing a national annual users meeting designed to allow organizations to share their successes as well as lessons learned. TeamSTEPPS in Minnesota

Minnesota facilities are also successfully incorporating TeamSTEPPS. The University of Minnesota Medical Center, Fairview integrated these principles into its Safe Surgery Process, encouraging every person in the room to speak up when safety or quality might be compromised. Stratis Health, the stateâ&#x20AC;&#x2122;s Quality Improvement Organization, uses TeamSTEPPS to help improve communication and patient safety in a variety of settings, from nursing homes to critical access hospitals. Recently the Minneapolis Veterans Affairs (VA) Health Care System introduced TeamSTEPPS on one inpatient unit. VA staff, from nurses to hospitalists, pharmacists to social workers, and even environmental services, underwent a 3.5-hour training session that included simulated exercises to practice these new skills. Within days, staff members noticed a more supportive culture on the unit.

Within days, staff members noticed a more supportive culture on the unit. The Minnesota Hospital Association and the Minnesota Alliance for Patient Safety (MAPS) are collaborating to develop an evidence-based â&#x20AC;&#x153;Roadmap to a Culture of Safety.â&#x20AC;? This document is designed to be a detailed implementation plan for fostering a culture of safety at any health care site, from small clinics to large health care organizations. One crucial domain for developing and sustaining such a culture is teamwork, and the primary source of information used to create this domain was TeamSTEPPS. This roadmap is in the final stages of development; more information can be found at the MAPS website, www.mnpatientsafety.org/. However, in order to fully develop cultures of safety and effective teams, it is essential to equip not only our current health care providers with these skills but also those in training. Many medical schools across the country, including the University of Minnesota and the University of North Dakota, are developing courses to educate their students in these essential teamwork skills. Increasingly, this is occurring in the interprofessional setting, and almost always by adapting TeamSTEPPS concepts for learners. TeamSTEPPS is also being used successfully at the graduate medical education level. The Accreditation Council on Graduate Medical Education, which accredits all residency training programs in the U.S., now requires them to include curricula on communication, professionalism, and system improvement. TeamSTEPPS has been a natural fit for addressing these essential skills. Though extensive research has shown these teamwork skills to improve outcomes in industries like aviation and nuclear power, the research is just emerging in health care. In locations throughout the country, TeamSTEPPS has been found to decrease adverse events, improve communication, and even to improve patient,

staff, and provider satisfaction. The University of Minnesota, along with Fairview Health Systems, is leading a national effort to study the effects of in situ (on the ward) simulation on decreasing adverse events in obstetrics using TeamSTEPPS. The Mineapolis VA is examining the effects of TeamSTEPPS training on staff satisfaction, team behaviors, and patient outcomes. Simple in theory, challenging in practice

One of the challenges of TeamSTEPPS implementation is that the skills appear deceptively simple to health care providers. We have come to expect that improvements in patientsâ&#x20AC;&#x2122; health require investment in costly complex technology. But what can appear simple in theory can be quite challenging in practice. Straightforward individual skills, when used con-

sistently and correctly, can translate into highly effective teams composed of people who are adaptive and communicate well. In other high-stakes industries with similar challengesâ&#x20AC;&#x201D;technical complexity, a history of rigid hierarchy, life-threatening emergenciesâ&#x20AC;&#x201D;this approach has been shown to prevent error and improve safety. We have only recently started to understand and to harness the power of these skills in health care. Itâ&#x20AC;&#x2122;s time for Nancy to be able to speak up, and to be thanked for doing so. The safety of our patients requires that we become All-Pro in this most important of team sports. Karyn D. Baum, MD, MSEd, is an associate professor of medicine and the associate chair of clinical improvement in the Department of Medicine at the University of Minnesota Medical School. She is also the director of the Minnesota TeamSTEPPS Training Resource Center. Albertine S. Beard, MD, is an assistant professor of medicine at the University of Minnesota and practices internal medicine at the Minneapolis VA Medical Center. She is a TeamSTEPPS Master Trainer.

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PROFESSIONAL

R

Advances and challenges are changing the face of radiology By Scott R. Schultz, MD

Regulation and reimbursement issues

Many areas of medicine are facing increased regulation and decreased reimbursement, but these issues have hit radiology particularly hard in the last two years. Preauthorization requirement. One of the more challenging hurdles has been the requirement of “preauthorization” prior to ordering a high-tech imaging exam, such as an MRI or CT scan. In the past, if a physician

wanted to order a CT scan for a patient, the order would be given and the physician’s office would call the imaging center and schedule it. Within the past few years, however, several large third-party payers have instituted the requirement of preauthorization prior to scheduling a high-tech exam. There are two basic forms of preauthorization: (1) by telephone and (2) computer-based. Preauthorization by telephone involves the physician’s office calling an 800 number and describing the high-tech exam the physician wants to order and the clinical reason(s) for ordering it. In the past, if a physician wanted to order a head CT for headache, there were no issues scheduling the

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RADIOLOGY

Spotlight on imaging

adiology remains one of the most technologically advanced fields in medicine, leading to exciting breakthroughs in the diagnosis and treatment of many different diseases. Along with these advances have come challenges. The most formidable changes currently facing radiology are: • Increased regulation along with decreased reimbursement • Commoditization of radiology, in association with the emergence of “nighthawk” and “day hawk” imaging companies

driven by your

U P D AT E :

MINNESOTA PHYSICIAN MARCH 2012

exam. With preauthorization, headache alone would be rejected as an acceptable reason for getting the head CT. The office would be told over the phone that the study was not authorized for headache, and therefore would not be covered by insurance. In order for the study to be authorized, the patient would need to have headache plus photophobia, weakness, or any number of associated symptoms. The computer-based model of preauthorization involves the scheduler logging onto a website and then entering the patient data and clinical reasons for the exam. If the study is authorized by the online system, then it can be scheduled. If the study is denied in either model, the ordering physician can choose to simply not have the exam done, or can interact over the phone or online to jump through enough hoops to get the study approved. Additionally, the ordering physician can move forward with the test even if the appeal is denied. In that case, the center performing the study will not get reimbursed but the ordering physician will receive the clinical information necessary to care for the patient. Obviously, the preauthorization requirement adds an extra “hassle factor” when ordering a high-tech exam. The end result is that preauthorization leads to fewer high-tech exams being performed; whether they are appropriate or not remains an open question. Looking ahead most leaders in radiology feel that some form of preauthorization is here to stay. Reimbursement. Reimbursement cuts are affecting all areas of medicine; however, imaging has been a special focus of cuts by the Centers for Medicare & Medicaid Services (CMS). A prime example of a drastic cut that affected imaging

last year was CMS’ “bundling” of CPT codes. Specifically, CMS decided that because CT Abdomen and CT Pelvis were often ordered together, the two exams would be bundled into a single exam—resulting in a dramatic decrease in reimbursement. This single move by CMS led to numerous imaging facilities across the country closing their doors. We can likely expect CMS to bundle more imaging codes in the future. Imaging accounts for a large part of the health care dollar. This fact has attracted the attention of many payers, but the government in particular. The Deficit Reduction Act of 2005 (DRA) called for annual scheduled cuts for all physicians. Fortunately, Congress has continued to postpone many of the cuts, thanks in part to efforts by medical societies, including the American College of Radiology (ACR) and the Radiology Business Management Association (RBMA). Additionally, the DRA resulted in a draconian cut in the technical component of imaging a few years ago. Outpatient imaging has two billing components: the professional component goes to the physician interpreting the images, and the technical component covers the cost of the imaging equipment, technical staff, and its associated overhead. There are two main fee schedules for outpatient imaging. The Medicare Physician Fee Schedule is linked to the RBRVS (resource-based relative value scale) and applies to imaging services provided in a freestanding physician office setting. The OPPS (outpatient prospective payment system) applies to imaging services provided in a hospital outpatient setting. Both fee schedules are based on the resources required to provide the particular service and the historical costs associated with providing said service. CMS decrees that the technical component always be paid at the lesser of the two fee schedules. The combination of legislative cuts such as CT Abd/Pelvis bundling and the DRA were so significant that some imaging centers closed, and many remaining imaging centers are


postponing upgrading their current equipment to the latest technology. Technological advances

Over the past decade, technological advances in digital imaging and picture archiving and communication systems (PACS) have transformed the practice of radiology. Digital imaging has completely changed the layout of an imaging department. With digital imaging, there are no more X-ray films and, thus, no need for darkrooms, film rooms/ libraries, or film clerks. The digital images can be read anywhere on a high-resolution monitor with high-speed Internet connectivity and the proper software. This technology has been of particular benefit to radiologists serving rural and remote areas and/or multiple sites. PACS allow for these digital images to be stored online, so that physicians can view images online without needing to go to the radiology department. PACS technology has transformed the culture of the radiology department. In the past, all specialists would come through the radiology department on a daily basis to view the films of their patients and converse with the radiologists. This no longer occurs, because both the images and the report can be viewed on any computer connected to the health system. The result is that the radiologist and the referring physicians have more time and can be more efficient; however, the loss of doctor-to-doctor interaction has isolated the radiologist. The relationships that radiologists traditionally had with their referring physicians have become harder to maintain. In the 2000s, as digital imaging and PACS were changing the nature and culture of radiology departments, “nighthawk” radiology companies sprang up around the globe. The term refers to radiologists reading images remotely. Initially, nighthawk services were provided by radiologists living in a different country and different time zone. A CT scan done at 3 a.m. in Minnesota

Radiology remains the noninvasive window into the human body and the diseases that affect it. could be interpreted by a radiologist in India during the middle of the day there, due to the difference in time zones. Again, this made life more efficient for the U.S.-based radiologists, yet at the same time it isolated them further from emergency department and other physicians. Nighthawk radiology companies rapidly became more prevalent in the U.S. and eventually began offering “day hawk” services: board-certified specialists available to read images night and day, 24 hours a day, seven days a week. These companies began to compete with each other on pricing, further eroding radiologist incomes. The latest development is nighthawk companies purchasing whole radiology practices across the U.S., truly making imaging a commodity—and devaluing it as a specialty—in the eyes of many key players in health care. Redefining our future

Radiologists clearly face an uncertain economic future. Some independent practices are folding, being purchased by nighthawk companies, or becoming employed by hospitals/health care organizations. However, other independent practices are meeting the current challenges by providing: (1) unique services (e.g., on-site minimally invasive image guided procedures), (2) high quality, upto-date imaging technology, and (3) on-site leadership (medical directors who ensure the appropriateness, quality, and safety of the exams). These leading-edge radiology practices are adding value to the care delivery process by providing timely and accurate subspecialty diagnostic information to help patients heal more quickly and avoid expensive unnecessary invasive procedures. Radiology practices that remain independent are also doing so by diversifying—for example, having interventional

radiologists perform procedures such as epidural steroid injections, venous ablation, and cosmetics in an office-based setting. Interventional radiologists are recognized as experts in minimally invasive procedures, so for many it is a natural extension of their practice. Radiology is fortunate to have major support from the ACR and RBMA organizations, as well as other radiology and medical societies. The ACR and RBMA do an outstanding job of keeping the membership abreast of the sweeping current and future changes they face. Additionally, these organizations are working proactively on Capitol Hill, trying to assure that every patient’s imaging study is of the highest quality, safe, and most appropriate.

I personally interpreted the theme of the ACR meeting in spring 2011 as: “The future of radiology is bright, just not necessarily for radiologists—unless they redefine their own futures.” At a November 2011 meeting of the Radiological Society of North America, John Patti, MD, current chair of the ACR Board of Chancellors, said this about the challenges facing our specialty: “We need to recast an introspective spotlight on ourselves and determine who we are [and] what value we provide.” Radiology remains the noninvasive window into the human body and the diseases that affect it. The future of radiology is bright indeed; it’s up to radiologists to keep the spotlight shining down the right path. Scott R. Schultz, MD, is president of Minneapolis Radiology and current president of the Minnesota Radiological Society.

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15


SCREENING

A

government health panel—the United States Preventive Services Task Force (USPSTF)—has decided that men should no longer be screened for prostate cancer with a PSA (prostate specific antigen) test. This position contradicts the recommendations of other professional organizations and leaves men and physicians confused and uncertain about PSA screening. To help clinicians understand this dilemma, this article reviews the background and recent research on PSA screening, summarizes screening guidelines, and offers screening recommendations to help primary care physicians advocate for their patients.

Background

Prostate cancer is common; in the U.S., there were an estimated 240,890 new cases and 33,720 deaths in 2011. With widespread PSA testing in the 1990s, prostate cancer diagnosis has nearly doubled, but in the past two decades the incidence has declined and mortality rates have fallen about 33 percent.

The prostate cancer dilemma To screen or not to screen By Thomas J. Stormont, MD For many years, the DRE (digital rectal examination) was the primary screening tool; however, the majority of cancers found were at an advanced or metastatic stage, when there was often symptomatic urinary tract obstruction or bony metastasis, in men 75 years old. In the postPSA era, most cases are asymptomatic, 80 percent are confined to the prostate, and only 4 percent have metastasized, with an average age at diagnosis of 67. However, most prostate cancer seems to be indolent, and autopsy studies commonly have shown that 70 percent of men over age 70 have occult prostate cancer. The vast majority of men with prostate cancer die of other causes. Unfortunately, PSA screening alone does not

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GUIDELINES

MINNESOTA PHYSICIAN MARCH 2012

accurately “risk-stratify” the innocuous cancers from the potentially life-threatening aggressive cancers. There are other considerations that further confound PSA screening. Certain clinical scenarios can affect PSA levels: For example, PSA can increase due to benign enlargement as well as infection, and can decrease by 50 percent in men being treated for an enlarged prostate with finasteride or dutasteride. After a patient has had a catheterization, prostate biopsy, or urinary tract infection, PSA testing should be postponed for at least a month (however, ejaculation and digital exam have generally shown negligible PSA effects). Lab variability can yield results that differ by 25 percent, depending on the type of assay used, so it is important to try to use a single lab for longitudinal monitoring. Attempts to improve upon PSA diagnostic accuracy have been implemented. The arbitrary PSA cutoff of 4.0 ng/ml is no longer considered a valid threshold because prostate cancer is found in a significant number of men with PSA <4.0, especially if there is an abnormal DRE. The use of age-adjusted PSA levels recognizes this and has resulted in the increased number of cancer diagnoses in younger men and a decline in diagnosis in older men. Other modifications to improve PSA testing include the use of free PSA, PSA velocity (rate of change), and PSA density (PSA/gland volume). Also, there are continuing efforts to discover and implement new biomarkers for prostate cancer (i.e., the PCA3 urine test). While all these modifications and markers have shown promise, their impact on screening has not yet been validated or proven consistent or useful.

Conflicting results of screening trials

More confusion about PSA screening arises from the conflicting published results of the three most recent prospective, randomized, controlled screening trials. The PLCO (Prostate, Lung, Colon and Ovary) study involved PSA screening in 76,693 men in the U.S. The authors concluded there was no improvement in prostate cancer mortality at seven years between the screened and control groups (Andriole et al., N Engl J Med, March 2009). However, a recent subgroup PLCO analysis (Crawford et al., Jrnl Clin Onc, Feb. 2011) found healthy men under 65 who were screened had a significant decrease in prostate cancer death. The ERSPC (European Randomized Study of Screening for Prostate Cancer) study reported on the effects of PSA screening of 181,160 men (Schröder et al., N Engl J Med, March 2009). As in the PLCO study, no difference in death rate was found at seven years—but at nine years, a 20 percent reduction in prostate cancer was found in men who had been screened. The authors estimated that 1,410 men would need to be screened and 48 would need to be treated to prevent one death. The Göteborg (Sweden) randomized screening trial involved 10,000 patients (Hugosson et al., Lancet Oncology, August 2010). At 10 years, its findings were similar to those of the ERSPC study, but at 14 years the authors found increasing survival benefit in the screened patients—a 50 percent reduction in mortality in the screened group. It was estimated in this study that a total of 293 men needed to be screened and only 12 treated to prevent one death. There are some significant differences and criticisms in the methodology among these three studies, the most cited being the contaminated control group and short study period in the PLCO study. However, it is apparent that with longer follow-up, there is a significant and increasing survival benefit to PSA screening.


Costs of PSA screening

Finally, the subject of cost and morbidity from PSA screening must be addressed. An abnormal PSA often leads to a prostate biopsy, a five-minute office procedure that can cause stress, bleeding, pain, and, rarely, infection. It is the prostate biopsy— not the PSA—that actually establishes the diagnosis of prostate cancer. Overall, it is estimated that 32 percent of Medicare patients who undergo prostate biopsy are found to have cancer, and this rate increases with patient age and PSA value. In the February 2011 issue of the Journal of Clinical Oncology, prostate cancer researcher Peter Carroll, MD, wrote that the main problem with PSA screening is that “diagnosis is almost uniformly followed by treatment and thus overtreatment.” FDA-approved treatment options include (alone or in combination): active surveillance, radiation, cryoablation, androgen ablation, and radical prostatectomy. The main long-term side effects of all these treatments, except for active sur-

Virtually all guidelines recommend a shared decision-making model for PSA testing. veillance, can be long-term urinary incontinence, sexual dysfunction, rectal problems, and depression. The yearly dollar cost of prostate cancer screening, estimated to be in the billions of dollars, can be difficult to quantify. And this cost accrues over time—not just from screening but also from primary therapy, subsequent surveillance, and treatments of side effects and/or salvage therapies for failures. To date, organizations that have established guidelines for prostate cancer screening have not yet considered economics in their recommendations. However, it appears inevitable that the financial burdens of screening will become an increasing consideration by policymakers, especially with the passage of the 2009 Accountable Care Act. Screening guidelines

Summaries of some medical groups that have published

guidelines regarding PSA screening are summarized below. Screening often includes both PSA and DRE. High-risk refers to blacks and patients with firstdegree relatives diagnosed with prostate cancer. Shared decisionmaking means an informed discussion between the patient and physician. The testing interval is usually annual. 1. American Cancer Society (ACS): Shared decision-making at age 50 (40–45 for highrisk men). 2. American College of Preventive Medicine (ACPM): Shared decision-making at age 50 (at younger age for high-risk men). Screening questionable in older men with chronic illnesses and life expectancy less than 10 years. 3. American Urological Association (AUA): Shared decision-making at age 40 and life expectancy of at least 10 years.

4. European Association of Urology (EAU): Shared decision-making at age 40. Screening probably not needed for patients older than 75 with PSA <3.0. 5. National Comprehensive Cancer Network (NCCN): Shared decision-making at age 40. For PSA >1.0 or if the patient is black, screen yearly PSA. For PSA <1.0, screen PSA yearly beginning at age 45. If PSA remains <1.0, screen PSA yearly beginning at age 50. 6. United States Preventive Services Task Force (USPSTF): Recommends against PSA screening in healthy asymptomatic men regardless of age, family |history, or ethnicity. Discussion

It is important for physicians to give open-minded consideration to PSA screening and not dismiss it uniformly as nonbeneficial, given that, of all medical groups with guidelines, only the PROSTATE to page 38

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SCREENING

Screening mammography

I

t has been a little more than two years since the U.S. Preventive Services Task Force (USPSTF) changed its recommendations regarding screening mammography for women (www.uspreventiveservicestask force.org/uspstf/uspsbrca.htm). Controversial among the scientific community, the guidelines clearly have had the intended effect of decreasing the number of screening mammography exams across the country. In addition, the Canadian Task Force on Preventive Health (CTFOPH) recently made similar recommendations (www.cmaj. ca/content/183/17/1991.full). Briefly, the USPSTF recommended that women 50–74 years of age have a screening mammogram every two years, rather than every year; that women 40–49 years of age not undergo routine screening; and that for women age 75 and over, there isn’t enough information to determine whether screening is useful. Why are these recommendations suspect?

Task force guidelines underestimate the benefit By Joseph H. Tashjian, MD Task force issues

First, the members of the U.S. and Canadian task forces were chosen specifically for their presumed lack of a conflict of interest. In practical terms, however, if you don’t have a conflict of interest, you likely don’t have any expertise in the field. Yet despite their lack of expertise, the task force members have been unwilling to debate the issues with any screening experts. Rather, they have relied on advice from epidemiologist Peter Gøtzsche, MD, of Denmark’s Nordic Cochrane Centre, who has been opposed to breast cancer screening for over a decade and has stated there is no benefit from screening for women at any age. Numerous analysts have refuted his analysis, and a

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recent letter to the editor of the Lancet journal, signed by more than 40 experts in breast health care from around the globe, said the Cochrane Centre promoted an “active anti-screening campaign based on erroneous interpretation of data from cancer registries and peer reviewed articles” (Lancet, Nov. 2011). Ironically, the Canadian task force chose Gøtzsche to write in support of their recommendations. In essence, Gøtzsche and the Cochrane Centre have eliminated studies that have shown a benefit for screening, based on alleged “technical flaws,” and have included only those studies that have not shown a benefit— and then have trumpeted the latter studies as being the only valid examination of screening. It is particularly disappointing that the studies that did not show a benefit had major flaws in design and performance, including poor mammography and placement of women with palpable lumps and advanced cancer in the screening arm. In addition, the task force based its recommendations primarily on randomized control trials without looking at other means of assessment. While such trials are helpful, they have a major drawback: Once you are assigned to the control side or the study side, you stay there, whether or not you receive the treatment or exam. If a woman is randomized to the screening side but doesn’t get the screening study, she still remains in the screening group. Conversely, if she is included on the control side but feels screening mammography is useful and gets it on her own, she still stays in the control side. This “contamination” is significant. The first major trial to evaluate screening mammography was the Health Insurance Plan (HIP) of Greater New York trial, initiated in December

1963. Only 67 percent of the women assigned to screening received any screening, and only 40 percent received all four screening examinations. Despite this contamination, the HIP study still found a 15 percent reduction in mortality. If you look at the women in this group who were actually screened, the death rate was cut by 49 percent, far exceeding the 15 percent originally reported (and, now, quoted by the task forces in their recommendations). There are other means of assessing the value of screening mammography. In Sweden, the county nurse is responsible for making sure that everyone follows the guidelines set by the county. Women are strongly encouraged to obtain a screening mammogram, and participation is higher than 95 percent. Each county can decide whether to begin screening mammography at age 40 or age 50. Studies have shown that women in their 40s had a 48 percent lower risk of death from breast cancer than those not screened. In Canada, similar results are seen in women from British Columbia, where there was a 40 percent decrease in deaths among women screened between the ages of 40 and 79, and a 39 percent reduction in women age 40–49, during the period 1988–2003 (Tabar L, et al., Lancet, 2003). A recent Swedish study by Hellquist et al. demonstrated a 29 percent reduction in mortality in women 40–49 years of age (Hellquist, BN et al., Cancer, 2010). What about screening every two years, rather than every year, in women in the 50–75 age range? There are good data to show that screening every two years instead of every year will increase mortality 20 percent. This is even more true in women aged 40–49 with breast cancer, among whom the cancers tend to grow and spread more rapidly. In fact, if women in this age group are screened every three years, there is little benefit at all. It is annual screening that provides the most benefit. In addition, for approximately 85 percent of women with breast cancer, their only risk factor is being a woman.


Basing screening on having a family history of breast cancer, as recommended by the task forces, means we will miss nearly all of the breast cancers until they are too large to ignore. Other concerns

Other concerns expressed by the task forces pertained to the accuracy of mammography, potential breast cancers caused by radiation exposure over time, and presumptive “harms” such as the pain and suffering associated with mammography and biopsies. The pain of mammography is nothing compared to the preparation for colonoscopy; however, no one is recommending not having screening colonoscopy because of the pain and suffering associated with the preparation. Mammography is not perfect, and it does not detect every breast cancer. It does detect most of them, however, even in the 40–49 age group. Among 100,000 women in their 40s, there will be 200 naturally occurring breast cancers, more than 150 of which will be diagnosed by mammography; and there will be fewer than six cancers potentially induced by mammography over their entire lifetime, and those would be expected to be detected by continued screening. With the advent of digital mammography, detection has significantly improved in women with dense breasts, who typically are in the 40–49 age range. Digital mammography was not available for any of the clinical trials cited by the task forces. A large prospective trial by the American College of Radiology demonstrated an improved detection rate in women with dense breasts from a film/screen mammogram of 35–50 percent to up to 70 percent with digital mammography, and this was in the early experience with digital mammography. A recent study demonstrated a cancer detection rate 36 percent higher utilizing digital mammography over conventional film/screen mammography (Glynn CG et al., Radiology, Sept. 2011). What about related anxiety, pain, and suffering? Women are

concerned when they have a positive result from a mammogram, just as men and women are concerned when their chest X-ray shows a nodule in the lungs. For every 100 screening mammograms performed, 10 patients will be called back for additional examination, six of which will be found to be normal. Two may be asked to return in six months for a follow-up exam, and two to three may have a biopsy. Only one in four to five of those biopsies will be cancer. Biopsies are now done with needles on an outpatient basis with localized numbing, usually performed in less than an hour with only minor discomfort. The vast majority of women can resume normal activities, including work, immediately after the biopsy. Biopsies are frequently performed immediately after a recommendation, so that all diagnostic evaluation can be completed on the same day. This significantly decreases the anxiety that comes with mammography. Notably, the task force doesn’t talk about the pain and suffering in women who have cancer detected at a later stage, whose cancer would have been easily diagnosed earlier with screening mammography. Even if we said there was no improvement in mortality from screening (which there most definitely is), the ability to treat with less invasive surgery is important. Also, not having to get chemotherapy, lose your hair, become nauseated and experience complications or memory loss, develop a peripheral neuropathy, etc., post-chemo treatment is a huge plus for women. Since the onset of routine screening in 1990, the mortality rate from breast cancer, which had been unchanged for the preceding 50 years, has dropped by 30 percent. Although there are fewer women in their 40s with breast cancer, 40 percent of the life years saved by screening are in that same group, because they will live more years after their diagnosis and cure. In addition, screening mammography has continued to improve over the past 20 years, where the dose has been reduced and the detec-

tion rate improved. This has been accomplished by improvements in equipment, performance of the mammogram, and improvement in interpretation. There are newer technical improvements to digital mammography, such as digital tomosynthesis (3-D imaging), that will again move the diagnosis forward. None of these advances were present at the time of any of the screening trials cited by the task forces. Early detection, improved treatment

The goal of any screening study is to find the disease earlier, when it is more likely to respond to treatment. For some cancers, like lung cancer, finding the cancer earlier isn't helpful, because usually it has already spread by the time it is detected. Early detection just means patients are aware of their cancer longer, not that they have a longer life. For other cancers, such as testicular cancer, the treatment is effective at almost any stage, and early detection is not useful. In only a few cancers—such

as of the breast, colon or cervix—does screening find the disease early enough that treatment is useful and prolongs the patient’s life. The goal has always been to prevent cancer, rather than diagnose it earlier and treat it. Until we reach that point, however, screening combined with advanced treatment is the only method available to reduce the deaths from cancer. In summary, there is ample data to show at least 30 percent, and up to a 48 percent, improvement in mortality from breast cancer with screening. There has been a concomitant drop in mortality of 30 percent during the performance of widespread screening in the U.S. Newer techniques continue to improve detection while decreasing radiation dose, and better training and performance continue to evolve. To say otherwise is to misinterpret, malign, or grossly underestimate the benefit of screening mammography. Joseph H. Tashjian, MD, is a radiologist with St. Paul Radiology and is chief of staff at Regions Hospital in St. Paul.

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COMMUNITY CAREGIVERS 2012

Making a difference in Recognizing Minnesota’s volunteer physicians

“There’s no shortage of patients; we just try to get as much done as we can while we’re there.” Rod Brown, MD

Each year, Minnesota Physician Publishing honors physicians who have volunteered medical services in recent years. Through volunteer medical activities that span the globe, Minnesota’s volunteer physicians have provided medical care and medical education and expanded cross-cultural skills and understanding. Their compassion, commitment, and generosity reflect deeply held values of Minnesota’s medical community. Story by Scott Wooldridge

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MINNESOTA PHYSICIAN MARCH 2012

Providing care on the mosquito coast When Rod Brown, MD, first traveled to Puerto Lempira 14 years ago, he was struck by how undeveloped the port town was. No electricity. The only way into the town, located on Honduras’ isolated Atlantic coast region, was by airplane or boat. Other than the local priest’s dilapidated truck, the only things with wheels were wheelbarrows. A lot has changed since that time, Brown says. “Everybody has cell phones. There are cars and trucks and motorcycles, even taxis,” he says. “It’s just a dramatic transformation from this very remote, sleepy little village to a kind of bustling small town.” Still, the region, commonly called the Mosquito Coast, has a ways to go. The hospital that Brown works from on his yearly medical missions had running water for the first time last year. Electricity is supplied by generators and is sometimes intermittent. Some of the X-ray equipment dates from the Vietnam War era. “It’s pretty primitive,” Brown says. “The facility is quite poor so anything you can do to get patients in and out of the hospital is better. They have a nursing staff and beds for patients, but linen and food and those types of things have to be brought by the patients’ families. Brown has traveled every year for 14 years to Puerto Lempira as part of missions with International Health Service (IHS), a nonprofit relief organization that is based in Eden Prairie. Brown is past president of the group and has served as medical director. IHS sends large missions twice a year to the Honduran town. The main medical mission takes place in February, and can consist of as many as 120 medical, dental, and support staff. Brown, an internist with Glacial Ridge Medical Center in Glenwood, travels to Puerto Lempira as part of the February missions, and works

with a surgical team of eight to 12 people. He says his team will address a wide range of issues on any given mission, including removing tumors, fixing hernias, taking out tonsils, and repairing wounds from machetes or bullets. The hospital does have laparoscopic gear, so the visiting physicians also do some laparoscopic work, he adds. On a typical trip, Brown estimates, the surgical team will do 50 to 70 procedures over a 10-day period. “There’s no shortage of patients; we just try to get as much done as we can while we’re there,” he says. The missions also bring equipment and medical supplies with them. “The hospital has some supplies, but we don’t want to use them all up. We’re there to work with them and support them; what we don’t use we leave for their use,” Brown says. He notes that Standard Fruit, which owns the Dole brand, works with IHS to bring two container loads of supplies to the hospital every year. Having made so many trips, Brown has become good friends with some physicians in Puerto Lempira and he says his familiarity with the town has advantages. “You can step right in and know what to expect,” he says. “You know the staff, and they know you, so you don’t have to recreate the wheel each time. It makes for a smoother operation.” The trips have also allowed him to show his children what medical missions are like, Brown notes. “My son is now a physician in training … and he got interested in medicine and surgery from going down there as a high school student,” Brown says. “My daughter likewise had an interest and she’s in her fourth year of dental school at the University of Minnesota. That was a great opportunity and motivator for her.”


Minnesota and the world Outside the comfort zone Loree Kalliainen, MD, recently made her third trip to India to do medical mission work. Unlike her first two trips, Kalliainen organized the latest mission herself, taking five other medical professionals from Minnesota deep into one of India’s poorest regions, to a hospital that had never seen an American physician before. “It’s seven hours northwest of Calcutta in a very rural area called Jharkhand. No tourists ever go up there,” says Kalliainen. “It’s very impoverished, even for India.” Kalliainen, a plastic surgeon who is chief of staff past at Regions Hospital in St. Paul, planned the trip after meeting an Indian physician, Sister Victoria Aind, MD. Aind had asked Kalliainen to come and do a plastic surgery mission at the hospital Aind runs, Holy Cross Belatanr. The small convent hospital has one floor and 25 beds. It is located in a compound that holds the hospital and a leprosarium— Kalliainen notes that leprosy is still seen on a regular basis in the area. After raising the money—Kalliainen estimates it cost each member approximately $5,000 for the entire trip—and doing planning and preparation, the team left for India in February 2011.

KELLY KADUCE “Ms. Kaduce’s warm and tender singing conveyed the aching vulnerability of the foolishly trusting Butterfly.” — The New York Times

Kalliainen describes the trip as a fascinating experience. “Everything about India is a massive sensory assault,” she says. “It’s loud and noisy and smelly and colorful. It just took

“Everything about India is a massive sensory assault.” Loree Kalliainen, MD

me right out of my comfort zone.” But Kalliainen enjoyed the challenge, and she says her team did as well. “I’ve been lucky because the people I’ve chosen to bring with me on trips are of like mind. I don’t want anybody whining about the food or making comments about having to bathe with a bucket of water poured over our head. It’s an amazing opportunity ... I try to never be the ugly American.” Aind had asked Kalliainen to bring a team for a plastic surgery camp in part because rural India has a high number of burn cases. People in the region use open fires to cook and commonly use kerosene lanterns, and

simple accidents often lead to serious buns. “There are still a few cases where people will set each other on fire, “ she adds. “Women will set each other on fire if one was looking at another women’s husband.” Burn treatments and cleft lip repair were the vast majority of the mission’s work, and Kalliainen says those treatments can make a big difference. “If their lips weren’t fixed, these kids would be outcasts forever,” she notes. “If I do a relatively simple hand surgery or scar release on an arm, now they can work.” Despite the primitive conditions—“I don’t bring any electrical equipment because it will just be blown apart by the Indian power grid; what little there is of it,” Kalliainen says—the team was productive, doing more than 60 operative procedures in one week. “We just have some flashlights in the room, and when the power goes out … you just keep operating under flashlight,” she says. Kalliainen speaks fondly of the local community. “I think it’s wonderful to see that people are the same everywhere; you hear that all the time and it really is true,” she says. “Even with the immensity of the poverty, people are content, happy, and very pleasant. It’s just really an amazing experience.” Caregivers to page 22

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COMMUNITY CAREGIVERS 2012 The program has been recognized for its efforts to overcome barriers to care. In 2010, it was given the Governor’s Council on Faith and It’s not a major commitment of time, Patrick Heller, MD, says; just a few Community Service Initiatives Best Practices Award. The award is a hours a month. The facilities are modest; a basement of a church, with recognition of faith and community organizations that create best praca physician, a nurse, and a few volunteers. The service provides only tice models for bringing together private and government resources to basic screening and primary health care services. address community needs. Project H.E.A.L. has also received a Federal Yet Project Health, Education, Access, Link (H.E.A.L.) serves a popuCommunity Access Program grant in recent years to assist with outlation that may not have any other regular access to health care. The reach efforts in the St. Cloud metro area as well as the surrounding program was launched after local churches asked CentraCare Health rural areas. System to help provide basic health services for the homeless and uninHeller says the scope of practice is limited but helpful. “Maybe a sured people in St. Cloud. Since then, the health system has partnered 2-year-old has an ear infection, and we can see him, so they don’t have with many groups, including Catholic Charities, to go the ER,” he says. “Even just a clinic visit or an the Boys & Girls Club, the Robert Wood Johnson urgent care visit is going to be pretty expensive for Foundation, and United Way St. Cloud, to fund and them if they don’t have insurance.” maintain health care clinics in Cold Spring, Long Other issues the clinic treats includes upper respiraPrairie, Melrose, St. Cloud, and Waite Park. tory infection, back pain, and minor injuries. Patients The program began in 1999, and now has more with more serious conditions can be referred to other than 70 volunteers. The CentraCare Health Founfacilities. Heller notes in one case where a cancer was dation and Mid-Minnesota Family Medicine Center diagnosed, the clinic was able to send the patient on to supply equipment, and pharmaceutical companies a specialist. Other resources are available too—for donate medical supplies and sample medications. example, at Heller’s clinic a nutritionist is often avail“It’s a program to try to get care to people who able to talk to patients about healthy eating. don’t have insurance,” Heller says. “There’s a popula“ Some of what they Delivering health care can be as much about protion of people who don’t come in because they don’t viding moral support as administering medicine or need is reassurance, have insurance and maybe aren’t in a position where treatments, Heller notes. “There are some people that they can go through all the paperwork. But being part and they feel better just come frequently with fairly minor issues,” he says. of the community, you want to serve those people’s from the reassurance “Some of what they need is reassurance, and they feel needs too.” better just from the reassurance you give.” you give.” Heller says that most of the people he sees are The program is rewarding and also eye-opening, Hispanic and he guesses that a good number of them Patrick Heller, MD Heller says. “It just give you a little more insight into are undocumented. He says that he doesn’t ask—his other people who are out there; the people you don’t emphasis is on giving care. “If I can use my professee in the [regular] clinic. And it gives you a little more sional skills in that way, it makes sense,” he says. “We insight into what immigrants are dealing with.” don’t restrict it in any way.”

Overcoming barriers to care

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>ŽĐĂƚĞĚ ŝŶ ƚŚĞ ŚĞĂƌƚ ŽĨ ƚŚĞ dǁŝŶ ŝƟĞƐ ĂƐƚ ĂŶŬ ĐĂŵƉƵƐ͕ ŽLJŶƚŽŶ ,ĞĂůƚŚ ^ĞƌǀŝĐĞ ŝƐ Ă ǀŝƚĂů ƉĂƌƚ ŽĨ ƚŚĞ hŶŝǀĞƌƐŝƚLJ ŽĨ DŝŶŶĞƐŽƚĂ ĐŽŵŵƵŶŝƚLJ͕ ƉƌŽǀŝĚŝŶŐ ĂŵďƵůĂƚŽƌLJ ĐĂƌĞ͕ ŚĞĂůƚŚ ĞĚƵĐĂƟŽŶ͕ ĂŶĚ ƉƵďůŝĐ ŚĞĂůƚŚ ƐĞƌǀŝĐĞƐ ƚŽ ƚŚĞ hŶŝǀĞƌƐŝƚLJ ĨŽƌ ŶĞĂƌůLJ ϵϬ LJĞĂƌƐ͘ /ƚ͛Ɛ ŽƵƌ ŵŝƐƐŝŽŶ ƚŽ ĐƌĞĂƚĞ Ă ŚĞĂůƚŚLJ ĐŽŵŵƵŶŝƚLJ ďLJ ǁŽƌŬŝŶŐ ǁŝƚŚ ƐƚƵĚĞŶƚƐ͕ ƐƚĂī͕ ĂŶĚ ĨĂĐƵůƚLJ ƚŽ ĂĐŚŝĞǀĞ ƉŚLJƐŝĐĂů͕ ĞŵŽƟŽŶĂů͕ ĂŶĚ ƐŽĐŝĂů ǁĞůůͲďĞŝŶŐ͘

ŽLJŶƚŽŶ ,ĞĂůƚŚ ^ĞƌǀŝĐĞ ŚĂƐ ĂŶ ŝŵŵĞĚŝĂƚĞ ŽƉĞŶŝŶŐ ĨŽƌ Ă ĨƵůůͲƟŵĞ ƉŚLJƐŝĐŝĂŶ ƚŽ ƉƌŽǀŝĚĞ ƐĞƌǀŝĐĞƐ ŝŶ ƚŚĞ WƌŝŵĂƌLJ ĂƌĞ ĂŶĚ hƌŐĞŶƚ ĂƌĞ ůŝŶŝĐƐ͘ ĂŶĚŝĚĂƚĞƐ ƐŚŽƵůĚ ĞŶũŽLJ ǁŽƌŬŝŶŐ ŝŶ Ă ĐŽůůĞŐĞ ŚĞĂůƚŚ ĞŶǀŝƌŽŶŵĞŶƚ ǁŝƚŚ Ă ůĂƌŐĞ ĂŶĚ ĚŝǀĞƌƐĞ ƉŽƉƵůĂƟŽŶ ŽĨ ƐƚƵĚĞŶƚƐ ĂŶĚ ƐƚĂī͘

ŽLJŶƚŽŶ͛Ɛ ŽƵƚƐƚĂŶĚŝŶŐ ƐƚĂī ŽĨ ϮϱϬ ŝŶĐůƵĚĞƐ ďŽĂƌĚ ĐĞƌƟĮĞĚ ƉŚLJƐŝĐŝĂŶƐ͕ ŶƵƌƐĞ ƉƌĂĐƟƟŽŶĞƌƐ͕ ƌĞŐŝƐƚĞƌĞĚ ŶƵƌƐĞƐ͕ DƐͬ>WEƐ͕ ƉŚLJƐŝĐŝĂŶ ĂƐƐŝƐƚĂŶƚƐ͕ ĚĞŶƟƐƚƐ͕ ĚĞŶƚĂů ŚLJŐŝĞŶŝƐƚƐ͕ ŽƉƚŽŵĞƚƌŝƐƚƐ͕ ƉŚLJƐŝĐĂů ĂŶĚ ŵĂƐƐĂŐĞ ƚŚĞƌĂƉŝƐƚƐ͕ ƌĞŐŝƐƚĞƌĞĚ ĚŝĞƟƟĂŶƐ͕ ƉŚĂƌŵĂĐŝƐƚƐ͕ ƉƐLJĐŚŝĂƚƌŝƐƚƐ͕ ƉƐLJĐŚŽůŽŐŝƐƚƐ͕ ĂŶĚ ƐŽĐŝĂů ǁŽƌŬĞƌƐ͘ KƵƌ ŵƵůƟĚŝƐĐŝƉůŝŶĂƌLJ ŚĞĂůƚŚ ƐĞƌǀŝĐĞ ŚĂƐ ďĞĞŶ ĐŽŶƟŶƵŽƵƐůLJ ĂĐĐƌĞĚŝƚĞĚ ďLJ , ƐŝŶĐĞ ϭϵϳϵ͕ ĂŶĚ ǁĂƐ ƚŚĞ ĮƌƐƚ ĐŽůůĞŐĞ ŚĞĂůƚŚ ƐĞƌǀŝĐĞ ƚŽ ŚĂǀĞ ĞĂƌŶĞĚ ƚŚŝƐ ĚŝƐƟŶĐƟŽŶ͘

dŚĞ ƋƵĂůŝĮĞĚ ĂƉƉůŝĐĂŶƚ ŵƵƐƚ ďĞ D^ ďŽĂƌĚ ĐĞƌƟĮĞĚͬĞůŝŐŝďůĞ ĂŶĚ ŚĂǀĞ ƚƌĂŝŶŝŶŐ ĂŶĚͬŽƌ ĞdžƉĞƌŝĞŶĐĞ ŝŶ ĂŶ ŽƵƚƉĂƟĞŶƚ ƉƌĂĐƟĐĞ ĂŶĚ ƵƌŐĞŶƚ ĐĂƌĞ͘ <ŶŽǁůĞĚŐĞ ŽĨ ĞůĞĐƚƌŽŶŝĐ ŚĞĂůƚŚ ƌĞĐŽƌĚƐ ǁŽƵůĚ ďĞ ďĞŶĞĮĐŝĂů͘ dŚŝƐ ƉŽƐŝƟŽŶ ŽīĞƌƐ Ă ĐŽŵƉĞƟƟǀĞ ƐĂůĂƌLJ͕ D ŽƉƉŽƌƚƵŶŝƟĞƐ͕ ĂŶĚ Ă ŐĞŶĞƌŽƵƐ ĂĐĂĚĞŵŝĐ ƐƚĂƚƵƐ ƌĞƟƌĞŵĞŶƚ ƉůĂŶ͘ WƌŽĨĞƐƐŝŽŶĂů ůŝĂďŝůŝƚLJ ĐŽǀĞƌĂŐĞ ŝƐ ƉƌŽǀŝĚĞĚ͘

ƩĞŶĚŝŶŐ ƚŽ ŽǀĞƌ ϭϬϬ͕ϬϬϬ ƉĂƟĞŶƚ ǀŝƐŝƚƐ ĞĂĐŚ LJĞĂƌ͕ ŽLJŶƚŽŶ ,ĞĂůƚŚ ^ĞƌǀŝĐĞ ƚĂŬĞƐ ƉƌŝĚĞ ŝŶ ŵĞĞƟŶŐ ƚŚĞ ŚĞĂůƚŚ ĐĂƌĞ ŶĞĞĚƐ ŽĨ h ŽĨ D ƐƚƵĚĞŶƚƐ͕ ƐƚĂī͕ ĂŶĚ ĨĂĐƵůƚLJ ǁŝƚŚ ĐŽŵƉĂƐƐŝŽŶ ĂŶĚ ƉƌŽĨĞƐƐŝŽŶĂůŝƐŵ͘

dŽ ůĞĂƌŶ ŵŽƌĞ͕ ƉůĞĂƐĞ ĐŽŶƚĂĐƚ ,ŽƐĞĂ KũǁĂŶŐ͕ ,ƵŵĂŶ ZĞƐŽƵƌĐĞƐ ŝƌĞĐƚŽƌ͕ Ăƚ (612) 626-1184, hojwang@bhs.umn.edu ƉƉůLJ ŽŶůŝŶĞ Ăƚ ŚƩƉƐ͗ͬͬĞŵƉůŽLJŵĞŶƚ͘ƵŵŶ͘ĞĚƵ and reference ƌĞƋƵŝƐŝƟŽŶ ŶƵŵďĞƌ 175782͘ dŚĞ hŶŝǀĞƌƐŝƚLJ ŽĨ DŝŶŶĞƐŽƚĂ ŝƐ ĂŶ ƋƵĂů KƉƉŽƌƚƵŶŝƚLJ͕ ĸƌŵĂƟǀĞ ĐƟŽŶ ĚƵĐĂƚŽƌ ĂŶĚ ŵƉůŽLJĞƌ͘

ϰϭϬ ŚƵƌĐŚ ^ƚƌĞĞƚ ^ ͻ DŝŶŶĞĂƉŽůŝƐ͕ DE ϱϱϰϱϱ ͻ ;ϲϭϮͿ ϲϮϱͲϴϰϬϬ ͻ ǁǁǁ͘ďŚƐ͘ƵŵŶ͘ĞĚƵ

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MINNESOTA PHYSICIAN MARCH 2012


One new area for his group in building local capacity is the use of interactive training videos. With the help of a software developer, CSI is As medical director of Children’s Surgery International (CSI), Peter producing a series of DVDs that feature real surgeries, with interactive Melchert, MD, takes a big-picture approach to medical missions. Not “hot spots” placed over relevant areas of anatomy that users can click only does his Minneapolis-based group help needy children—with a on to choose the right instrument or procedure. The program will focus on fixing cleft palates—but under Melchert’s leadership it works assess mistakes or confirm proper decisions. to help the communities it visits improve their ability to provide their “The trainees can do that at home or at the hospital before we own medical services. ever come, and they’re miles ahead in terms of preparation,” Melchert “The question we ask ourselves is, are we fostering independence says. “Even the most low-resource hospital in Africa without electricity by building local capacity?” Melchert says. “Are we going to a place will have a computer for its physicians for continuing medical education where there's need and where our skills can be applied meaningfully, and communicating. It may be run by a little gas-powered generator, without taking away the job of a local physician?” but everyone has a computer. We can make this tool that runs on a Melchert began working with CSI in 2003, and he became its med- simple personal computer and broadly expand our trainee pool and ical director in 2004. In Minneapolis, Melchert is an internal medicine train faster and at less cost.” and pediatric hospitalist at Abbott Northwestern Hospital and In addition to fixing cleft palates, many of the missions include Children’s Hospitals and Clinics, but he describes his pediatric surgeons or pediatric urologists. Melchert work with CSI as a second full-time job. He makes as notes that hernias are a big problem in the developmany as three trips a year for the group, often ing world but that medical groups find it easier to assessing sites for future missions. fundraise for facial deformities than genital anomThat attention to detail and preparation is a key alies. By including surgical teams that can handle a part of his group’s philosophy, Melchert says. “Our range of problems, the group greatly increases the assessment is so comprehensive, I’m in the operatgood it can do. “Very simple treatments can have a ing room counting the number of outlets,” he says. great impact,” Melchert says. “I meet all the people we’ll be working with side-byAccording the Melchert, CSI is seeing an side … That’s really the only way to be effective.” increase in the number of physicians and medical Melchert, who also teaches as an assistant prostaff who volunteer for the overseas work. He says fessor for the University of Minnesota’s Global “Very simple treatments physicians tell him the work revitalizes their practices Health Course, says he has seen warehouses full of at home. “I find that when I’m working overseas, donated equipment that will never be used because can have a great impact.” I’m doing the things I thought I would be doing, facilities don’t have electricity or local physicians back when I was a medical student. All the doctors Peter Melchert, MD aren’t trained on the equipment. His group believes and nurses that come on these trips tell me the in working closely with local physicians, training same thing: ‘This is why I went into medicine.’” them to do the work so that further missions from Caregivers to page 24 U.S. doctors won’t be needed.

Healing patients, building capacity

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COMMUNITY CAREGIVERS 2012 Recently, Slusher has been doing research on phototherapy using natural sunlight, and she notes her work has become a mix of research, training, and patient care. “There are a lot of blurred lines there. There’s Tina Slusher says medical mission work changes lives. She is an example a lot of teaching with the research, and there’s a lot of patient care in the teaching and in the research. It’s not a clear delineation.” herself—having gone from a general pediatric practice in eastern In addition to her work in Africa, Slusher has done teaching in Kentucky to a career where she devotes three to four months a year Thailand, which she says has significant cultural differences compared overseas, treating children and doing research. to Africa. “Generally speaking, Asia is more resourced and more highFor the past 22 years, Slusher has gone to Africa or Thailand every tech than Africa, of course excluding South Africa. Sub-Saharan Africa is year for extended medical missions, a devotion that has shaped the generally struggling a lot more with resources and basics like electricikind of practice she can do here in the United States. “It’s been a varity,” she says. “It’s a very different world. Asian culture moves a lot ety of arrangements,” she says. “I refuse to take a job where [overseas faster. African culture is much slower; relationships are important, time work] couldn’t be a significant part. The least I’ve negotiated is three is not important.” months; that’s the bare minimum I will agree to.” The lack of resources and high mortality among children can be Slusher works with a number of organizations, sometimes as a voldiscouraging, Slusher says. But she says she finds unteer and sometimes for varying amounts of pay. inspiration in the passion and hard work of her She says her devotion to mission work comes from African colleagues, who carry on despite huge chalseeing the challenges that both patients and physilenges. She adds that her faith also plays a role. “I cians face in developing nations. “I work with some see my faith as part of what I do every day. I really absolutely wonderful African doctors,” she adds. think God expects us to do what we do and do it “They need U.S. colleagues, to be able to do what very well.” they do for their kids. They need our collaboration.” Slusher is on staff at Hennepin County Medical Slusher’s main area of focus in Africa has been Center and a faculty member of the Global newborn jaundice, an easily treated condition in the Pediatrics program at the University of Minnesota. U.S. that is a major killer of newborn children in She says her teaching position gives her an excelcountries like Nigeria, where she has done much of lent opportunity to promote overseas medical work “It completely changes her work. to medical students. “I encourage every medical “Many of the places in Nigeria that are trying how you practice medicine student or resident to go at least once because it to take care of newborn jaundice don’t have consiscompletely changes how you practice medicine in in the United States.” tent electricity or don’t have electricity at all. They the United States, even if you never go back,” don’t have good phototherapy units even if they Tina Slusher, MD Slusher says. “It makes you more conscious and less happen to have electricity,” she says. “That’s part of wasteful. I believe that you’re a better physician [if the reason that so many children are dying or disyou take part in a medical mission].” abled from jaundice.”

A lifelong devotion to medical missions

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MINNESOTA PHYSICIAN MARCH 2012

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funds for equipment and travel expenses. A typical trip, Treacy says, includes approximately 10 volunteers, including two physicians. In addition to providing laser treatments at Milton Cato Memorial Hospital in Kingstown, they often travel to medMany medical missions involve large organizations and impressive ical sites around the islands, visiting clinics with primitive facilities. Each amounts of logistics, but medical volunteer work in developing countrip lasts a week and the medical team typically treats 400 to 600 tries can exist on a smaller scale as well. Kevin Treacy, MD, an ophthalpatients in that time period. The staff works long hours, Treacy notes. mologist from Duluth, has proved that with his Project SCENE. “I’ve never brought sunscreen because I’ve been inside pretty much The project’s name reveals its roots: Sister Congregations Enjoying sunup to sundown,” he says. “There’s that much work to do.” New Eyesight (SCENE) was born when Treacy traveled to his church’s The SCENE program is also training local physicians to do eye prosister diocese in Kingstown, the capital of St. Vincent and the Grenacedures so patients can continue to be treated on a regular basis. Treacy dines. The Caribbean nation consists of 32 islands says he has cut back on cataract surgery because north of Venezuela and near Grenada. some patients told local surgeons they wanted to wait St. Vincent, with a population of 125,000, is for the American doctors. “You can become counterpoor and has traditionally had a high rate of diabetes productive in terms of our goal of trying to support and related conditions such as diabetic retinopathy. local doctors and their practices,” he says. “That can That condition is a leading cause of blindness cause a threat to their livelihood and a threat to the throughout the world for people aged 25 through permanent care that we want to see in place.” 65, Treacy notes. To support the local health care system in St. Treacy first visited Kingstown in 1999, and began Vincent, Treacy donated a cash award he received in laying the groundwork for regular ophthalmology 2004 from the Minnesota Academy of Ophthalmolmissions to treat diabetic retinopathy and other eye ogy toward training a physician from St. Vincent. The conditions. With the help of groups such as the physician has since begun offering cataract surgery in Rotary Club and the Lions Club in Minnesota, he his clinic, Treacy notes. “That’s our goal, to give them raised enough money to purchase two lasers for the tools they need, the education to do the work. treating eye conditions. Before Treacy’s efforts, no Basically, I’d love to put myself out of business.” such technology was available in St. Vincent. Treacy says he’s found work very rewarding “There was no real funding available for that “That’s our goal, to give and has enjoyed taking his the family along to help with care,” Treacy says. “Either a family could come up them the tools they need.” the medical missions. “It’s been very fulfilling effort,” with money [to fly to another country for treatment], he says. “Eye care is universally appreciated, so even Kevin Treacy, MD or they would basically lose their vision.” when there are political or cultural differences, it’s Since his first trip in August 2000, Treacy has something that we can all enjoy.” visited the island nation 18 times. In addition, he has

Project SCENE brings eye care to Caribbean island

spent many hours working in Minnesota to raise

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Caregivers to page 26

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Fairview Health Services Leading the way in innovation Fairview is seeking compassionate and adventurous caregivers—four full-time physicians and eight full-time nurse practitioners/physician assistants—to join us in developing a unique new outpatient care model. Highlights of this opportunity include: • Care for adult patients with complex medical and behavioral needs— those not well-served in the traditional outpatient clinic—through development of a primarily home-based practice • Partner with a Fairview Medical Group team who has demonstrated the capacity to provide compassionate, high-quality and efficient care for a similarly complex patient population • Provide outpatient care only; inpatient care provided by our team of hospitalists and our community and academic medical centers Candidates must have 7+ years experience as a practicing clinician. Emphasis in hospital-based medicine, cardiac, pulmonary or end-of-life care preferred. Visit fairview.org/physicians to explore this and other opportunities and apply online, call 612-672-2277 or email recruit1@fairview.org. Sorry, no J1 opportunities.

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MINNESOTA PHYSICIAN

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COMMUNITY CAREGIVERS 2012

The outsider experience

something that Doctors Without Borders took very seriously. “We would get into our Land Rovers behind a locked gate, and Patrick Ebeling, MD, a surgeon with Twin Cities Orthopedics, is relathey would open the gate and we’d drive to the hospital, then we tively new to medical missions. His first, to Haiti, came just months after would get out behind another locked gate,” he says. “They wanted us the devastating earthquake that destroyed much of the nation’s capitol, to be careful to wear our Doctors Without Borders shirt at all times, so Port-au-Prince. His second was to Port Harcourt in Nigeria, a city so they know you’re a doctor and not an oil worker, because that’s who plagued by kidnappings of westerners that the group sponsoring the they are usually looking to kidnap.” mission, Doctors Without Borders, required Ebeling to sign a proof-ofAs part of an international team sponsored by the Paris-based life document in case he was abducted. group, Ebeling provided surgical care at a free trauma center at a hospi“Filling out that form was definitely a moment where I thought, tal in Port Harcourt. The port town was a rough place, and Ebeling ‘What am I doing here?’” Ebeling says. notes that the lack of traffic controls leads to many auto accidents and But despite the eye-opening circumstances of his first two medical injuries. “There’s an unbelievable number of cars hitting pedestrians, missions, Ebeling admits that he has “caught the bug” and that was a lot of what we saw,” he says. “In a place and is looking forward to doing more. And he says even where everybody’s scraping for what they can get, there the discomfort of working in a very different culture can are a lot gunshot wounds and machete injuries. A lot of be seen in a positive light. interpersonal violence.” “You definitely feel unsettled,” he says. “That unsetAlthough physicians with the program were retled feeling is one of the benefits. I think being able to stricted in where they could travel because of safety recall that feeling of being so unsettled and being so concerns, Ebeling said he never felt he was in any danmuch the outsider makes you a more empathetic person, ger. “I felt safe the whole time, and I think that’s a testanot just in your job but in your daily life.” ment to how they run the program.” Ebeling first traveled to Port-au-Prince with Project Ebeling said the African trip was a little stressful on Medishare in May 2010, where he worked in a tempohis family, but he was surprised at how quickly things rary hospital offering follow-up care for people who had got back to normal when he returned. “Even after a been in injured in the January earthquake. He traveled month away, after two or three days of being back “That unsettled there again in September 2011 for a week, again seeing you’re kind of back into your routine. You definitely feeling is one of earthquake victims but also treating congenital condihave a different perspective on how much you can get tions and common, day-to-day injuries. done with different equipment and how much you can the benefits.” In May of 2011 Ebeling went on a longer, onedo in a rough situation,” he notes. “But it is possible to Patrick Ebeling, MD month mission to Port Harcourt with Doctors Without be gone for a month and experience something like this Borders. The city, with a metro population of approxiand help some people, and then get back to normal life mately 1.5 million people, is the center of Nigeria’s oil when you come back.” industry, and kidnappings of westerners for ransom is

Chief Medical Officer

We iinvite We nvite you you to to eexplore xplore our opportunities opport rtunities iin: n: our IInn tthe he heart heart ooff the the Cuyuna Cuyuna Lakes Lakes rregion egion Minnesota, Crosby ooff M innesota, the the medical medical campus campus iinn C rosby iincludes ncludes C uyuna Regional Regional Medical Medical Center, Center, Cuyuna a ccritical ritical aaccess ccess hospital hospital aand nd clinic clinic offering offering ssuperb uperb new new facilities facilities with with tthe he latest lattest m edical medical ttechnologies. echnologies. Outdoor Outdoor activities activities aabound, bound, Cities metropolitan aand nd with with the the TTwin win C ities m etropolitan area area away, jjust ust a short short ddrive rive aw ay, yyou ou can can experience experience tthe he perfect perfect balance balance ooff recreational recreat ational and and ccultural ultural activities. activities. EEnhance nhance yyour our professional professional life life in in an an eenvironment nvironment that that pprovides rovides eexciting xciting practice practice Northwoods oopportunities pportunities in in a bbeautiful eautiful N orthwoods ssetting. etting. welcomes TThe he Cuyuna Cuyuna Lakes Lakes rregion egion w elcomes you. you.

• Family Medicine • Internal Medicine • Hospitalist

Contact: Todd Todd Bymark, ark, tb tbymark@cuyunamed.org ymark@cuyunamed.org www.cuyunamed.or org (866) 270-0043 / (218) 546-4322 | www.cuyunamed.org

26

MINNESOTA PHYSICIAN MARCH 2012

Rice Memorial Hospital has an outCandidates submit a cover standing opportunity for the right letter and resume to: person to serve as its Chief Medical Michael Schramm, CEO Officer (CMO). Rice Memorial Hospital Reporting directly to the CEO, this 301 SW Becker Avenue Willmar, MN 56201 senior executive will be responsible for leading the medical staff in the planRice provides a competining, facilitating and implementing of tive salary and generous programs to enhance physician effecbenefit package. To learn tiveness, quality of practice, clinical more see our website at integration and patient satisfaction. www.ricehospital.com The CMO will be line administrator for physician services within the Emergency Department and is expected to provide direct patient care at least four shifts per month in the Emergency Room. The position requires an MD or DO with a license to practice medicine in the State of Minnesota; as well as a minimum of seven years of clinical experience and at least two years of physician leadership experience. An MBA or Masters degree in public health is desirable. Located in the lakes region two hours west of the Twin Cities, Rice Memorial Hospital is the state’s largest municipal hospital, providing a vast array of services to the residents of west central Minnesota, including high-tech diagnostics, rehabilitation, long-term care, DME, mental health, dialysis, radiation oncology and hospice. Rice recently completed a $52 million building and renovation project.


Psychiatrist 40 Hour Work Week

FAMILY PRACTICE w/OB Crookston, MN and Roseau, MN

The Federal Medical Center, Rochester, MN, is an accredited Joint Commission medical and behavioral health referral center for the Federal Bureau of Prisons.

• Country Lifestyle.... Urban Technology • Dedicated Team Approach • Competitive Salary & Benefits

Psychiatrists work closely with a multi-disciplinary team consisting of health care, mental health care, social work, rehabilitation services, and correctional professionals to provide diagnostic and treatment services to federal inmates.

Idylic Practice Opportunities located in family friendly communities. Leave the hassle and bustle of the city behind.

The Federal Bureau of Prisons, Health Services Division, is committed to providing evidence-based medical and psychiatric treatment and has a national impact through the development of comprehensive medical and psychiatric clinical guidelines. The Federal Bureau of Prisons offers a competitive salary and benefits package. The Federal Bureau of Prisons is an Equal Opportunity Employer.

Contact: Kerri Hjelmstad, Physician Recruiter Altru Health System PO Box 6003 Grand Forks, ND 58201-6003

Contact: Lynn Platte, Assistant Human Resource Manager

1-800-437-5373 Fax: 701-780-6641 khjelmstad@altru.org

lplatte@bop.gov or call (507) 424-7521

www.altru.org

Family Medicine

Practice Well. Live Well.

St. Cloud/Sartell, MN

Lake Region Healthcare is located in a magnificent, rural, and family-friendly setting in Minnesota lakes country where we aim to be the state’s preeminent regional health care partner.

We are actively recruiting exceptional part-time or full-time BC/BE family medicine physicians to join our primary care team in Sartell, MN. This is an out-patient only opportunity and does not include labor and delivery or hospital call and rounding. Our current primary care team includes family medicine, adult medicine, OB/GYN and pediatrics. Previous electronic medical record experience is preferred but not required. We use the Epic electronic medical record system at all of our clinics and admitting hospitals.

Our award winning patient care and uncommon medical specialties set us apart from other regional health care groups. Lake Region’s physicians and their families also enjoy an unmatched quality of professional and personal life. Current opportunities including competitive salary and benefit packages available for BE/BC physicians are: • Dermatologist • Family Medicine • General Surgery • Hospitalist

Our HealthPartners Central Minnesota Clinics – Sartell moved into a new primary care clinic in the summer 2010. We offer a competitive salary, an excellent benefit package, a rewarding practice and a commitment to providing exceptional patient-centered care. St Cloud/Sartell, MN is located just one hour north of the Twin Cities and offers a dynamic lifestyle in a growing community with a traditional appeal.

• Internal Medicine • Pediatrics • Emergency Medicine

For more information contact Barb Miller, Physician Recruiter bjmiller@lrhc.org • (218) 736-8227

For more information, please contact diane.m.collins@ healthpartners.com or call Diane at 800-472-4695 x3. EOE

712 Cascade St. S., Fergus Falls, MN 736-8000 • (800) 439-6424

Lake Region Healthcare is an Equal Opportunity Employer. EOE

healthpartners.com

www.lrhc.org ©

MARCH 2012 MINNESOTA PHYSICIAN

27


P S Y C H I AT RY

A

t age 45, Suzanne had suffered from anxiety and depression her entire life, although she was not clinically diagnosed until early adulthood. She had been on and off antidepressant therapy for nearly 20 years, but recently had found her depression so disabling that she could barely interact with family and friends or continue her work as a dental hygienist. Caroline described her life as a “pernicious hell” of voices in her head, unshakable despondency, and daily thoughts of suicide. Decades of talk therapy, meditation, and antidepressant drugs—Zoloft, Lexapro, Wellbutrin—all had failed to lift her black cloud of depression. At age 50, the married mother of two teenaged daughters was actively fantasizing about taking her own life. Suzanne and Caroline are typical of patients suffering from treatment-resistant depression, or TRD. Their depression is lifelong and overpowering, and they have found antidepressants partially or completely ineffective.

A breakthrough in treating depression Transcranial magnetic stimulation By Abraham Verjovsky, MD

And over the years, they had lost hope of ever finding relief or truly enjoying their lives. The downsides of antidepressants are well known. Aside from their slow and often inconsistent effectiveness, they come with an army of side effects— insomnia, anxiety, weight gain, fatigue, bowel complications, sexual dysfunction, and more. The primary alternative has been electroconvulsive therapy (ECT), the modern version of the old electroshock treatments so grimly depicted in movies like “One Flew Over the Cuckoo’s Nest.” ECT has been dramatically refined over the years and it is highly effective and safe for TRD patients, but it carries significant baggage as well; it

Internal Medicine?

Yup.

Family Medicine?

NEW clinic in Mahtomedi, MN?

Internal and Family Medicine Opportunities Stillwater Medical Group is an 90+ provider multi-specialty group practice affiliated with Lakeview Hospital. For more than 50 years we have been providing comprehensive healthcare services in the St. Croix Valley, just east of the Twin Cities metro area. Internal and Family Medicine Physician Opportunities: Stillwater Medical Group has exciting new Internal and Family Medicine Physician opportunities at our NEW Mahtomedi, MN clinic opening Fall 2012! Additional opportunities also available in Stillwater, MN. Mahtomedi, MN? (Ma-toe-me-dye) So what if you can’t pronounce it? We can help with that. Mahtomedi is located in Washington County, on the east shore of White Bear Lake. Residents appreciate the community’s small town charm, lakeside flavor, and close proximity to the Twin Cities Metropolitan Area. In addition, the Mahtomedi School District and other area colleges offer excellence in education. For further information please contact: Patti Lewis, Director Human Resources 1500 Curve Crest Blvd, Stillwater MN (651) 275-3304, plewis@lakeview.org stillwatermedicalgroup.com

28

We’ll make it all better.

MINNESOTA PHYSICIAN MARCH 2012

requires general anesthesia and causes significant confusion and memory loss in many patients. Other options, such as vagus nerve stimulation and deep brain stimulation, involve the significantly more invasive measure of brain surgery, and unfortunately are often less effective in treating depression. The sad fact is that many people with major depression never seek treatment, in part because the treatment options are scary. Over the past two years, however, Suzanne and Caroline and thousands like them have found release from their lifelong emotional imprisonment with a newly available technology called transcranial magnetic stimulation (TMS). I first began tracking the research into this technology a decade ago, followed its FDA clearance process, and began treating patients with it in 2010, shortly before the American Psychiatric Association added TMS to its treatment guidelines for major depression. Development of TMS

Since the days of Mesmer, magnetic forces have been thought to hold special power over human behavior. The earliest scientific attempts to use magnetic energy to alter brain activity were conducted by French physician and physicist J.-A. d’Arsonval in 1898 and by English electrical engineer S.P. Thompson in 1910. They built magnetic stimulators powerful enough to activate retinal cells, causing subjects to perceive light flashes, but the fields generated were too weak to stimulate brain tissue. Magnetic stimulation was used as a brain-mapping technique, but the observation that neuromodulation caused mood changes encouraged further research. It was not until 1985 that Anthony Barker at the

University of Sheffield, England, designed an instrument with sufficient power to activate cortical neurons and performed the first study of TMS. TMS therapy was approved by the FDA in 2008, based on studies proving its efficacy in the treatment for depression. Prior to receiving FDA approval, TMS already was in use in other countries, including Canada, New Zealand, and Israel, as a treatment for depression for patients who had not responded to medications and who might otherwise be considered for ECT. TMS uses highly focused electromagnetic pulses to directly stimulate the neurons in the location of the left prefrontal cortex that controls mood. TMS is an outpatient, noninvasive procedure that requires no anesthesia—the pulses are delivered by a coil that is positioned on the scalp, and the magnetic field passes through the skull and penetrates 2 to 3 centimeters into the targeted area. The patient experiences a tapping sensation on the skull (many have described it as a “woodpecker”), which can be irritating until the patient habituates to it but is rarely painful. A typical course of TMS treatment requires 20 to 30 daily sessions, five days a week for four to six weeks. Each treatment delivers a total of 3,000 pulses over the course of 37 minutes. These magnetic pulses cause neurons to fire and release neurotransmitters such as serotonin. The impact on the patient is often immediately evident— some patients have described it as a “light switch” clicking on. Two days prior to beginning TMS therapy, Caroline wrote in her journal that she was vividly imagining “a glass or two of wine, a very sharp razor, and lots of blood.” After her first two TMS treatments, her journal entry began, “Feel great!!!! … HAVE ENERGY!” Research on TMS has shown that half of the patients experience significant improvement in their symptoms, and one in three achieve actual remission. The success rate in my own clinical experience has surpassed the research num-


bers—I have seen dramatic improvement in 85 to 90 percent of my patients. This may be because most of them suffer from refractory depression. Anecdotal reports from TMS providers around the country show similar rates of success.

TMS is proving to be a valuable breakthrough, not just for psychiatrists but for family physicians whose patients’ lives are being affected, or even endangered, by intractable depression.

Limitations/contraindications

There are some precautions in the use of TMS. Patients with implanted metal devices in or around the head should not be treated, but dental implants are not generally a problem. TMS should be used with caution in patients with implanted pacemakers or cardioverter/defibrillators (ICDs). Comparison with other brain stimulation therapies

There are other innovative options to antidepressants, namely vagus nerve stimulation (VNS) and deep brain stimulation (DBS). Unfortunately, both options are quite invasive and therefore significantly riskier, as they both require surgery. With VNS, there are two implants. First, an electrical wire is coiled around the vagus, or 10th cranial nerve, as it exits the skull and passes through the left side of the neck. This connects to a pacemaker-like device that is implanted in the chest. After the patient heals from the procedure, typically two weeks later, the pulse generator is turned on for the first time. The physician in the office programs it, and it can be accessed through software in subsequent office visits. Though this treatment modality was FDAapproved for the treatment of TRD in 2005, it remains controversial because of its invasive nature, complications such as triggering sleep apnea, and low efficacy rates. As the name implies, deep brain stimulation involves surgically implanting electrodes under stereotactic guidance in an area of the brain known as Brodmann area 25, or the subgenual cingulate. As with VNS, the electrodes are connected to a pulse generator/power source implanted in the patient’s chest. Though DBS appears to have some promise, it remains an

experimental procedure and is not FDA-approved for treatment of depression. Most patients receiving DBS are involved in clinical trials. Further potential

TMS is proving to be a valuable breakthrough, not just for psychiatrists but for family physicians whose patients’ lives are being affected, or even endangered, by intractable depression. Many TMS providers are specialists to whom family doctors refer TRD patients in the same way they would refer a patient to an orthopedist for knee surgery. After a course of treatment, the patients return to the referring physician—ideally, in far better shape to handle whatever other medical challenges they may face. TMS is also an exciting new resource for ob-gyns with pregnant patients suffering from depression. Women of reproductive age make up a significant percentage of psychiatric patients, outnumbering men about two to one, and the hormonal changes of pregnancy can significantly exacerbate depression symptoms. Pregnant patients on depression medication—and their obstetricians— often face a potentially agonizing choice, because late-term antidepressant use has been shown to increase the risk of birth defects to the fetus. In order to protect their babies, women must often stop taking their medications just when they need them the most, and their doctors must constantly weigh the risk of unchecked depression to the mother versus the drug risk to the baby. With TMS, pregnant women and their doctors don’t have to make that difficult choice. TMS is completely noninvasive and safe for both the mother and the unborn child.

Fewer than 400 physicians nationwide currently are regularly using TMS. The barrier to faster and more widespread adoption of the technology is cost—health insurance doesn’t cover TMS (at least, not without a fight …), and most patients must pay out-of-pocket at a cost of $8,000 or more for a full course of treatment. As a result, doctors have been slow to make the considerable initial investment in the equipment. As TMS technology advances and more research on its use becomes available, insurers and physicians will become better versed in it. I expect this treatment modality to become a major influence on how we treat

depression in the future. It has already had that impact on my patients. The voices tormenting Caroline faded after a few treatments and have not returned. Her occasional depressive episodes are milder and of much shorter duration. She is medication-free and no longer has thoughts of suicide. “TMS pulled me from the abyss,” she wrote recently, “and I believe the change is permanent.” Suzanne believes, quite simply, that TMS saved her life. She remains on a daily antidepressant but is dramatically more functional—and happy. “I have never felt better in my life,” she writes. Abraham Verjovsky, MD, is certified by the American Board of Psychiatry and Neurology, and has been in private practice in Edina for more than 20 years.

Practice Well. Live Well.

Lake Region Medical Group is seeking a full-time Certified Physician Assistant to join our Lake Region Healthcare team of 3 orthopedic surgeons; providing care in a multi-specialty clinic with 50+ providers.We are looking for a hardworking, conscientious individual committed to providing quality care to our patients as we develop our Orthopedic Center of Excellence.

Duties will include new and follow-up patient visits, assisting with surgery, post-op visits and hospital rounds in our 108 –bed community based hospital.The ideal candidate will have 2-5 years experience in orthopedics. We offer a competitive salary with a healthy benefit package. For more information contact Barb Miller, Physician Recruiter bjmiller@lrhc.org • (218) 736-8227

712 Cascade St. S., Fergus Falls, MN 736-8000 • (800) 439-6424

Lake Region Healthcare is an Equal Opportunity Employer. EOE

www.lrhc.org MARCH 2012

MINNESOTA PHYSICIAN

29


T R A N S P L A N TAT I O N

T

he transplantation of vital vascularized organs has gone from the stuff of fiction to mainstream reality in the past 50 years. During that time, some of the most significant contributions have come from venerable regional institutions in the Upper Midwest, such as the University of Minnesota and the Mayo Clinic, where innovative and bold teams continue to have an impact on the field of organ transplantation. Organ donation

Transplantation is unique in medicine because of the inevitable involvement of multiple surgical teams in the performance of any transplant procedure. Because these teams are separate in time and even space, a highly complex system of organ donation and distribution has evolved to serve our patients. While highly regulated, this system is also highly transparent, with readily accessible data on the performance of transplant centers and organ procurement organizations provided by the Scientific Registry

From fiction to reality in half a century Organ transplantation in the Upper Midwest By William D. Payne, MD

of Transplant Recipients (SRTR). The SRTR is a database of transplantation statistics, which is administered by the Chronic Disease Research Group of the

In 2011, 526 transplants were performed with organs recovered from 160 organ donors in the LifeSource region. Minneapolis Medical Research Foundation, the research arm of Hennepin County Medical Center. These data are available to the public by accessing the SRTR website at www.srtr.org. Organ donation services in Minnesota, South Dakota, and

Freedom to Care and Freedom to Thrive with Allina Hospitals & Clinics We make a difference in the lives of our patients, our staff, and our communities. Physicians can focus on patient care and can professionally thrive in Allina, and the result is the quality of care for which we are known. We are based in Minneapolis, and have comprehensive services throughout Minnesota and in western Wisconsin. Become a part of the Allina team, joined together with a common purpose and uncommon caring. For more information, please contact: Kaitlin Osborn, Allina Physician Recruitment Toll-free: 1-800-248-4921 | Fax: 612-262-4163 Email: Kaitlin.Osborn@allina.com Website: allina.com/jobs EOE 10127 1211 ©2011 ALLINA HEALTH SYSTEM. ®A REGISTERED TRADEMARK OF ALLINA HEALTH SYSTEM

30

North Dakota are provided by LifeSource, one of 58 regionally distributed, nonprofit organ procurement organizations in the United States. LifeSource man-

MINNESOTA PHYSICIAN MARCH 2012

ages the authorization and organ recovery processes in partnership with the hospitals in our region. In 2011, 526 transplants were performed with organs recovered from 160 organ donors in the LifeSource region. In addition, LifeSource facilitates the transportation of organs imported from other regions of the country to the transplant centers in North Dakota, South Dakota, and Minnesota. LifeSource also has a vital role in informing the public about the need for donated organs. More than 3 million people in the three-state region are registered as organ and tissue donors, nearly all of them through the donor check-off on their driver’s licenses or state ID cards. The Department of Transportation in North Dakota and the departments of public safety in South Dakota and Minnesota have partnered with LifeSource to allow residents of the Upper Midwest to have the information they need to make an informed decision about donation when they are in the license office. In our region, 60 percent of licensed drivers have designated a desire to donate on their licenses, compared to 42 percent nationally. This is an admirable accomplishment, but one that can be improved upon. As of January 2012, Minnesotans can contribute $2 to sup-

port public education about organ, tissue, and eye donation with a check-off on their driver’s licenses or state ID applications. The money raised by the “You and $2” program will support public education about donation as part of the state’s commitment to ensure that Minnesotans have access to the necessary information that allows them to make a positive, informed decision about registering as an organ, tissue, and eye donor. Kidney transplantation

Kidney transplantation continues to thrive as a therapy for end-stage renal disease. Currently, there are four kidney transplant programs in Minnesota, all with fully mature teams providing excellent outcomes to the patients of the state. However, many patients remain on wait lists because they have formed antibodies against cell surface antigens. Exposure to these antigens in the form of pregnancies, transfusions, or prior transplants can stimulate the formation of antibodies which can lead to early, potent rejection and graft loss. If potential recipients develop multiple antibodies, their serum may react with the cell surfaces of available donors with the corresponding antigens, and this may preclude safe transplantation from those donors. To circumvent this occurrence, the antibody profile of the recipient is tested and characterized and a search is made for a potential donor with compatible antigens. If the only potential living donors available are deemed to be unsuitable because of incompatibility, the available donors of other recipients are screened, if they have agreed to participate. In its simplest form, the incompatibilities of two donor recipient pairs are solved by switching or exchanging donors. This strategy, known as “domino-transplants,” has been extended to form complex exchanges and chains of transplants involving multiple donorrecipient pairs at different centers. The kidney transplant centers in Minnesota are all active participants in nationwide paired-donation coalitions.


Regional transplant centers Heart transplantation

The three heart transplant centers in Minnesota are active in treating patients with end-stage heart failure with transplantation, as a first-line replacement therapy, and as a final therapy after bridging to transplant with artificial devices, both total heart replacement devices and left ventricular-assist devices. The results of these transplants are among the most successful, with patient survivals exceeding 90 percent one year after graft. Liver transplantation

Institution/location

Type of organ transplant

Abbott Northwestern Hospital Minneapolis, Minn.

Heart, kidney

Avera McKennan Hospital and University Health Center Sioux Falls, S.D.

Kidney, pancreas

Hennepin County Medical Center Minneapolis, Minn.

Kidney

Mayo Clinic Rochester, Minn.

Heart, kidney, liver, lung, pancreas, pancreatic islets

Medcenter One Health Systems Bismarck, N.D.

Kidney

Sanford Medical Center Fargo, N.D.

Kidney, pancreas

Sanford USD Medical Center Sioux Falls, S.D.

Kidney, pancreas

Our regional liver transplant University of Minnesota centers continue to deliver stateMedical Center, Fairview of-the-art care to patients at the Minneapolis, Minn. Mayo Clinic and the University of Minnesota, Fairview, and Lung transplantation Amplatz Childrenâ&#x20AC;&#x2122;s Hospital. Lung transplant programs have Since the development of the seen steadily improving results national transplant database in over the past decade but con1988, more than 100,000 liver tinue to face the challenge of a transplants have been reported profound shortage of suitable to the United Network for Organ organs for transplant. The lungs Sharing. In 2010, 6,291 liver are particularly susceptible to transplants were performed in damage during the dying the U.S., 124 in Minnesota. process in trauma patients and The most common indicain the intensive care unit envition for liver transplantation is ronment. Care from intensive cirrhosis caused by hepatitis C, care specialists and which accounts for advanced practice about 30 percent of Regional organ critical care nurses, cases. Cirrhosis due and tissue as well as expert to fatty disease of recovery services care by skilled the liver is rapidly LifeSource nurses in the hospiincreasing and has 2550 University tal intensive care increased as an etiAvenue West, units has improved ology of liver failSuite 315 South the prospects for ure, with transplanSt. Paul, Minnesota lung retrieval in tation rates rising 55114-1904 many more sixfold over the past www.life-source.org/ instances over the 10 years. Anti-viral past several years. treatment of hepatitis Nonetheless, the lungs remain C is still being developed, and the vital organ that is least likely recurrence after transplantation to be used in the organ donor, is almost universal at present. even in cases where the prospecWhile it remains an indolent tive donor previously was in disease in most recipients after excellent health. transplant, these recurrences are one of the thorniest problems Pancreas and pancreatic islet facing the transplant team in the transplantation care of their patients. Hope is Transplantation for the treatbuoyed by the excellent success treating patients with hepatitis B ment of insulin-dependent diawho receive transplants. In these betes continues to be a gratifying yet challenging part of solid cases, antiviral prophylaxis in organ transplantation. Suitable the peritransplant period can donor organs either are transprevent reinfection in the vast planted as whole vascularized majority of cases. New and emerging antiviral therapies pro- organs or are processed to extract the islets of Langerhans vide the prospect of more effecand transplanted in an injectable tive treatment of hepatitis C in form as clusters of cells. These the near future.

Heart, intestine, kidney, liver, lung, pancreas, pancreatic islets

islet-alone transplants are compelling because they eliminate the necessity of transplanting the exocrine pancreas, the source of much of the morbidity of whole-organ pancreas transplant. Islet transplants are done as a part of investigational protocols and have afforded select patients freedom from insulin therapy, but they are not yet refined to a point that they can

be broadly delivered to large numbers of patients. Wholeorgan pancreas transplants done alone or in combination with kidney transplants were performed in 1,200 patients in the U.S. last year and can render patients free of the need for insulin therapy in 80 percent or more of cases. This brief overview has touched upon only a few topics in the field of transplantation. Our regional transplant centers and LifeSource continue to make meaningful contributions to this discipline, supported in no small measure by the efforts of our regional hospitals that provide the care to our donors and their families. Through organ donation, transplantation is truly the delivery of care to suffering patients by the entire community. William D. Payne, MD, is medical director of LifeSource and a professor in the Department of Surgery at the University of Minnesota Medical School, Minneapolis.

Emergency Medicine Emergency Practice Associates has immediate full-time, part-time and locums opportunities at our sites in:

Hibbing Little Falls Park Rapids Alexandria Austin For more information contact Tina Dalton or Mike Coulter at 800-458-5003, email:

recruiting@epamidwest.com or visit our website at

www.epamidwest.com

Your Emergency Practice Partner MARCH 2012

MINNESOTA PHYSICIAN

31


St. Cloud VA Health Care System is accepting applications for the following full or part-time positions: • Anesthesiologist (St. Cloud) • Associate Chief, Primary and Specialty Medicine (Internist-St. Cloud) • Dermatologist (St. Cloud)

• Internal Medicine/ Family Practice (Alexandria, Brainerd, St. Cloud, Montevideo) • Medical DirectorExtended Care & Rehab (IM or Geriatrics) (St. Cloud) • NP/PA (Montevideo)

• Disability Examiner (IM or FP) (St. Cloud)

• Psychiatrist (Brainerd, St. Cloud)

• ENT (St. Cloud)

• Radiologist (St. Cloud)

• General Surgeon (St. Cloud) • Geriatrician (Nursing Home-St. Cloud) • Hematology/Oncology (St. Cloud)

• Urgent Care Provider (MD, PA or NP) • Weekend Medical Officer of the Day (IM or FP) (fee for service appointment, St. Cloud)

US Citizenship required or candidates must have proper authorization to work in the US. J-1 candidates are now being accepted for the Hematology/Oncology positions. Physician applicants should be BC/BE. Applicant(s) selected for a position may be eligible for an award up to the maximum limitation under the provision of the Education Debt Reduction Program. Possible relocation bonus. EEO Employer.

Excellent benefit package including: Favorable lifestyle

Competitive salary

26 days vacation

13 days sick leave

CME days

Liability insurance

Interested applicants can mail or email your CV to VAHCS

St.Health Cloud VA Care System Brainerd | Montevideo | Alexandria

Sharon Schmitz (Sharon.schmitz@va.gov) 4801 Veterans Drive, St. Cloud, MN 56303 Or fax: 320-654-7650 or Telephone: 320-252-1670, extension 6618

32

Look for the friendly doctor in a MN based physician staffing service ...

MINNESOTA PHYSICIAN MARCH 2012

Physicians: • Let us do your scheduling & credentialing • Paid Malpractice • Physician Friendly • Choose where and when you want to work • Competitve Rates • Courteous Staff

Clients: • Prevent loss of revenue • BC/BE physicians • Competitive rates • Quality coverage • Malpractice coverage paid by us

P-763-682-5906/F-763-684-0243 michelle@whitesellmedstaff.com www.whitesellmedstaff.com


2012 physician opinion survey 1of 4 7. I advise patients about matters of public health such as smoking, domestic violence, depression, drinking during pregnancy, drug use, etc., even if I am not seeing them for those specific reasons.

50 40 30

31.1%

20 16.2% 15

12.2%

10

0

7.4%

Strongly agree

Agree

No opinion Disagree

Strongly disagree

30

39.9%

40

41.2%

30 20

20

12.2%

3.4% Strongly agree

Never

3. There are unnecessary barriers to prescribing certain medications where I work.

No opinion Disagree

73.6%

29.7%

18.2% 12.2%

10 4.1%

Percentage of total responses

Percentage of total responses

Strongly agree

Agree

No opinion Disagree

Strongly disagree

40 30 20 4.1% Strongly agree

10.8%

8.8%

2.7% Agree

No opinion Disagree

80 60 40 20

13.5%

Strongly disagree

2.7% Yes

No

Donâ&#x20AC;&#x2122;t know/ does not apply

10. I have encountered patients I can identify as having fetal alcohol spectrum disorders. 50

48.6%

43.5%

25

0

4.1%

9. My practice screens patients about matters of public health such as smoking, domestic violence, drinking during pregnancy, drug use, etc.

50

5

6.1%

83.8%

35

15

10

100

35.8%

20

14.2%

15

Strongly disagree

6. I feel it interferes with the physician-patient relationship when clinics screen for data about public health such as smoking, domestic violence, depression, drinking during pregnancy, drug use, etc.

40

30

36.5%

25

0

0.7% Agree

50

0

Rarely

39.2%

20

0 Weekly

Strongly disagree

30

60

2.7% Daily

No opinion Disagree

5

70

10

Many times daily

12.8%

80

10

4.1%

22.3%

5. I have seen dramatic improvement in patients taking specialty pharmacy products.

Percentage of total responses

50 Percentage of total responses

40

0

2. How often do you prescribe medications described as specialty pharmacy?

0

50

10

5

60.8%

60

40 33.3% 30 20 14.3% 10

6.8%

Percentage of total responses

Percentage of total responses

25

Agree

3.4%

35 Percentage of total responses

33.1%

Strongly agree

40

Percentage of total responses

35

5.4%

80 70

30

9.5%

10

8. I feel that patients often do not provide accurate responses to my questions about their health status.

Percentage of total responses

1. I understand what is meant by the term specialty pharmacy.

25.7%

20

0

4. Patients for whom I have prescribed specialty pharmacy products have reported difficulty finding pharmacies that carry them.

58.8%

60 Percentage of total responses

We are pleased to present the results from the last of four physician opinion surveys we will publish in 2012.Through a number of sampling methods, we received 148 responses to Phase 1. If you would like to be included in future surveys, please contact us via e-mail at comments@mppub.com or call 612-728-8600.The surveys are online, are quick to complete, and are completely anonymous and confidential.We welcome your suggestions for this and future surveys. Our thanks to those who participated.

40 30

25.0%

26.4%

20 10

2.0% Strongly agree

Agree

No opinion Disagree

Strongly disagree

0

Strongly agree

Agree

No opinion Disagree

To participate in future surveys or offer suggestions, please contact us at comments@mppub.com.

Strongly disagree

0

MARCH 2012

Yes

No

Donâ&#x20AC;&#x2122;t know/ does not apply

MINNESOTA PHYSICIAN

33


ALLIED

S

ince 1990, Minnesota has been ranked among the top six healthiest states in America’s Health Rankings (an annual report by the United Health Foundation), and for seven of those years it held the No. 1 spot. However, as pressures on the health-care delivery system increase with the aging of baby boomers and increased patient access to health care insurance through the Affordable Healthcare Act, all states will be challenged to keep their citizens healthy. And providing them with access to highquality medical care will be a key component in this effort. As a result of these population and health-care system changes, physician-led, teambased care is taking center stage and becoming an important part of the health care model. The good news is that members of one group of non-physician clinicians—certified physician assistants (PA-Cs)—are already making an impact as members of physician-led teams in health care practices in every specialty and every state.

Physician assistants A critical and evolving role in team-based care By Pamela M. Dean, MBA

The National Commission on Certification of Physician Assistants (NCCPA) reports that in January 2012, more than 1,500 certified PAs were licensed to practice in Minnesota.

According to a 2000 study conducted by the NCCPA, physicians who are already working with certified PAs have experienced the positive impact they

Affiliated Community Medical Centers is a physician owned multispecialty group with 11 affiliate sites located in western and southwestern Minnesota. ACMC is the perfect match for healthcare providers who are looking for an exceptional practice opportunity and a high quality of life. Current opportunities available for BE/BC physicians in the following specialties: • Hospitalist • Infectious Disease • Internal Medicine • OB/GYN • Oncology • Orthopedic Surgery

• Psychiatry • Pediatrics • Pulmonary/ Critical Care • Radiation Oncology • Rheumatology

For additional information, please contact:

Kari Bredberg, Physician Recruitment karib@acmc.com, (320) 231-6366

Julayne Mayer, Physician Recruitment mayerj@acmc.com, (320) 231-5052

www.acmc.com

34

make on medical and surgical practices: • 94.2 percent of physician assistant employers say that certified PAs have helped increase the number of patients seen.

In recognition of this trend toward specialization, the NCCPA launched the Certificate of Added Qualifications (CAQ) program in 2011 as a complement to the existing certification process.

The perfect match of career and lifestyle. • ENT • Family Medicine • General Surgery • Geriatrician/ • Outpatient Internal Medicine

PROFESSIONS

MINNESOTA PHYSICIAN MARCH 2012

• 92.5 percent agree that certified PAs have enabled them to shorten the time patients must wait for appointments. • 91.2 percent say that certified PAs enable them to allow patients more time to ask questions during their office visits. Employers also give high marks on the quality of care, with more than 99 percent reporting that certified PAs provide high-quality health care, are compassionate clinicians, and are valuable members of the health-care delivery system. There are other benefits as well. According to a study by the American Medical Association, physicians in a solo practice who employed a physician assistant were able to work one week less per year on average, while providing greater access to care for their patients. All that said, bringing any clinician into a practice requires a foundation of mutual trust and respect, so it’s important that physicians considering introducing a certified PA to their teams understand the profession’s genesis, regulation, training, abilities, and credentials.

Emergence of the PA profession

The PA profession emerged in the mid-1960s in response to the shortage of doctors in the United States created by the post-World War II baby boom. The first PAs were Army, Air Force, and Navy medics returning from military service having received a tremendous amount of medical and surgical training and experience in the field. However, there was no place for them within the civilian health care system until the PA profession was created. The PA profession still has close ties to its roots, with certified PAs caring for the sick and injured in the Army, Navy, Air Force, and Coast Guard. Certified PAs are also widely deployed by the Department of Veterans Affairs (the nation’s largest employer of PAs). Today PAs work just about anywhere else you find physicians—from solo physician practices to large multispecialty clinics, hospitals, surgical centers, long-term care facilities, prison systems, and well beyond. While the first PAs were informally trained in the military, today’s PAs are formally educated in accredited programs, most of which award graduate degrees. Those programs include didactic training in medical and behavioral sciences and clinical rotations in internal medicine, family medicine, surgery, pediatrics, obstetrics and gynecology, emergency medicine, and geriatric medicine. Like physicians, PAs are licensed in every state. In Minnesota, PA practice is governed by the Minnesota Board of Medical Practice. To obtain NCCPA certification (a prerequisite for PA licensure in all states), graduates must pass a comprehensive national exam. To maintain certification, PAs must log 100 CME hours every two years and pass the Physician Assistant National Recertifying Examination every six years. In practice, certified PAs perform a wide variety of activiPAs to page 36


Opportunities available in the following specialty:

Olmsted Medical Center, a 150-clinician multi-specialty clinic with 10 outlying branch clinics and a 61 bed hospital, continues to experience significant growth. Olmsted Medical Center provides an excellent opportunity to practice quality medicine in a family oriented atmosphere. The Rochester community provides numerous cultural, educational, and recreational opportunities.

Family Medicine Rochester Northwest Clinic Rochester Southeast Clinic St.Charles Clinic Internal Medicine Southeast Clinic Occupational Medicine Southeast Clinic Dermatology Southeast Clinic

THE STRENGTH TO HEAL

and stand by those who stand up for me.

Send CV to: Olmsted Medical Center Administration/Clinician Recruitment

Learn the latest treatments and play an important role in the care of Soldiers and their Families. As a physician on the U.S. Army Reserve Health Care Team, youâ&#x20AC;&#x2122;ll continue to practice in your community and serve when needed. Youâ&#x20AC;&#x2122;ll work with the most advanced technology and distinguish yourself while working with dedicated professionals. Youâ&#x20AC;&#x2122;ll make a difference.

1650 4th Street SE Rochester, MN 55904

Olmsted Medical Center offers a competitive salary and comprehensive benefit package.

email: egarcia@olmmed.org

7R OHDUQ PRUH FDOO  RU YLVLW ZZZKHDOWKFDUHJRDUP\FRPT

Phone: 507.529.6610

Š 2010. Paid for by the United States Army. All rights reserved.

Fax: 507.529.6622 EOE

www.olmstedmedicalcenter.org

A Diverse and Vital Health Service

Boynton Health Service

Welcome to Boynton Health Service >Ĺ˝Ä?Ä&#x201A;Ć&#x161;Ä&#x17E;Ä&#x161; Ĺ?Ĺś Ć&#x161;Ĺ&#x161;Ä&#x17E; Ĺ&#x161;Ä&#x17E;Ä&#x201A;Ć&#x152;Ć&#x161; ŽĨ Ć&#x161;Ĺ&#x161;Ä&#x17E; dÇ Ĺ?Ĺś Ĺ?Ć&#x;Ä&#x17E;Ć? Ä&#x201A;Ć?Ć&#x161; Ä&#x201A;Ŝŏ Ä?Ä&#x201A;ĹľĆ&#x2030;ĆľĆ?Í&#x2022; Ĺ˝Ç&#x2021;ĹśĆ&#x161;ŽŜ ,Ä&#x17E;Ä&#x201A;ĹŻĆ&#x161;Ĺ&#x161; ^Ä&#x17E;Ć&#x152;Ç&#x20AC;Ĺ?Ä?Ä&#x17E; Ĺ?Ć? Ä&#x201A; Ç&#x20AC;Ĺ?Ć&#x161;Ä&#x201A;ĹŻ Ć&#x2030;Ä&#x201A;Ć&#x152;Ć&#x161; ŽĨ Ć&#x161;Ĺ&#x161;Ä&#x17E; hĹśĹ?Ç&#x20AC;Ä&#x17E;Ć&#x152;Ć?Ĺ?Ć&#x161;Ç&#x2021; ŽĨ DĹ?ŜŜÄ&#x17E;Ć?Ĺ˝Ć&#x161;Ä&#x201A; Ä?ŽžžƾŜĹ?Ć&#x161;Ç&#x2021;Í&#x2022; Ć&#x2030;Ć&#x152;Ĺ˝Ç&#x20AC;Ĺ?Ä&#x161;Ĺ?ĹśĹ? Ä&#x201A;ĹľÄ?ƾůÄ&#x201A;Ć&#x161;Ĺ˝Ć&#x152;Ç&#x2021; Ä?Ä&#x201A;Ć&#x152;Ä&#x17E;Í&#x2022; Ĺ&#x161;Ä&#x17E;Ä&#x201A;ĹŻĆ&#x161;Ĺ&#x161; Ä&#x17E;Ä&#x161;ĆľÄ?Ä&#x201A;Ć&#x;ŽŜÍ&#x2022; Ä&#x201A;ĹśÄ&#x161; Ć&#x2030;ĆľÄ?ĹŻĹ?Ä? Ĺ&#x161;Ä&#x17E;Ä&#x201A;ĹŻĆ&#x161;Ĺ&#x161; Ć?Ä&#x17E;Ć&#x152;Ç&#x20AC;Ĺ?Ä?Ä&#x17E;Ć? Ć&#x161;Ĺ˝ Ć&#x161;Ĺ&#x161;Ä&#x17E; hĹśĹ?Ç&#x20AC;Ä&#x17E;Ć&#x152;Ć?Ĺ?Ć&#x161;Ç&#x2021; ĨŽĆ&#x152; ĹśÄ&#x17E;Ä&#x201A;Ć&#x152;ĹŻÇ&#x2021; ϾϏ Ç&#x2021;Ä&#x17E;Ä&#x201A;Ć&#x152;Ć?Í&#x2DC; /Ć&#x161;Í&#x203A;Ć? ŽƾĆ&#x152; ĹľĹ?Ć?Ć?Ĺ?ŽŜ Ć&#x161;Ĺ˝ Ä?Ć&#x152;Ä&#x17E;Ä&#x201A;Ć&#x161;Ä&#x17E; Ä&#x201A; Ĺ&#x161;Ä&#x17E;Ä&#x201A;ĹŻĆ&#x161;Ĺ&#x161;Ç&#x2021; Ä?ŽžžƾŜĹ?Ć&#x161;Ç&#x2021; Ä?Ç&#x2021; Ç Ĺ˝Ć&#x152;ĹŹĹ?ĹśĹ? Ç Ĺ?Ć&#x161;Ĺ&#x161; Ć?Ć&#x161;ĆľÄ&#x161;Ä&#x17E;ĹśĆ&#x161;Ć?Í&#x2022; Ć?Ć&#x161;Ä&#x201A;ÄŤÍ&#x2022; Ä&#x201A;ĹśÄ&#x161; ĨÄ&#x201A;Ä?ƾůĆ&#x161;Ç&#x2021; Ć&#x161;Ĺ˝ Ä&#x201A;Ä?Ĺ&#x161;Ĺ?Ä&#x17E;Ç&#x20AC;Ä&#x17E; Ć&#x2030;Ĺ&#x161;Ç&#x2021;Ć?Ĺ?Ä?Ä&#x201A;ĹŻÍ&#x2022; Ä&#x17E;žŽĆ&#x;ŽŜÄ&#x201A;ĹŻÍ&#x2022; Ä&#x201A;ĹśÄ&#x161; Ć?Ĺ˝Ä?Ĺ?Ä&#x201A;ĹŻ Ç Ä&#x17E;ůůͲÄ?Ä&#x17E;Ĺ?ĹśĹ?Í&#x2DC; Ĺ˝Ç&#x2021;ĹśĆ&#x161;ŽŜÍ&#x203A;Ć? ŽƾĆ&#x161;Ć?Ć&#x161;Ä&#x201A;ĹśÄ&#x161;Ĺ?ĹśĹ? Ć?Ć&#x161;Ä&#x201A;ÄŤ ŽĨ ώϹϏ Ĺ?ĹśÄ?ĹŻĆľÄ&#x161;Ä&#x17E;Ć? Ä?Ĺ˝Ä&#x201A;Ć&#x152;Ä&#x161; Ä?Ä&#x17E;Ć&#x152;Ć&#x;ÄŽÄ&#x17E;Ä&#x161; Ć&#x2030;Ĺ&#x161;Ç&#x2021;Ć?Ĺ?Ä?Ĺ?Ä&#x201A;ĹśĆ?Í&#x2022; ŜƾĆ&#x152;Ć?Ä&#x17E; Ć&#x2030;Ć&#x152;Ä&#x201A;Ä?Ć&#x;Ć&#x;ŽŜÄ&#x17E;Ć&#x152;Ć?Í&#x2022; Ć&#x152;Ä&#x17E;Ĺ?Ĺ?Ć?Ć&#x161;Ä&#x17E;Ć&#x152;Ä&#x17E;Ä&#x161; ŜƾĆ&#x152;Ć?Ä&#x17E;Ć?Í&#x2022; DĆ?ÍŹ>WEĆ?Í&#x2022; Ć&#x2030;Ĺ&#x161;Ç&#x2021;Ć?Ĺ?Ä?Ĺ?Ä&#x201A;Ĺś Ä&#x201A;Ć?Ć?Ĺ?Ć?Ć&#x161;Ä&#x201A;ĹśĆ&#x161;Ć?Í&#x2022; Ä&#x161;Ä&#x17E;ĹśĆ&#x;Ć?Ć&#x161;Ć?Í&#x2022; Ä&#x161;Ä&#x17E;ĹśĆ&#x161;Ä&#x201A;ĹŻ Ĺ&#x161;Ç&#x2021;Ĺ?Ĺ?Ä&#x17E;ĹśĹ?Ć?Ć&#x161;Ć?Í&#x2022; Ĺ˝Ć&#x2030;Ć&#x161;ŽžÄ&#x17E;Ć&#x161;Ć&#x152;Ĺ?Ć?Ć&#x161;Ć?Í&#x2022; Ć&#x2030;Ĺ&#x161;Ç&#x2021;Ć?Ĺ?Ä?Ä&#x201A;ĹŻ Ä&#x201A;ĹśÄ&#x161; ĹľÄ&#x201A;Ć?Ć?Ä&#x201A;Ĺ?Ä&#x17E; Ć&#x161;Ĺ&#x161;Ä&#x17E;Ć&#x152;Ä&#x201A;Ć&#x2030;Ĺ?Ć?Ć&#x161;Ć?Í&#x2022; Ć&#x152;Ä&#x17E;Ĺ?Ĺ?Ć?Ć&#x161;Ä&#x17E;Ć&#x152;Ä&#x17E;Ä&#x161; Ä&#x161;Ĺ?Ä&#x17E;Ć&#x;Ć&#x;Ä&#x201A;ĹśĆ?Í&#x2022; Ć&#x2030;Ĺ&#x161;Ä&#x201A;Ć&#x152;ĹľÄ&#x201A;Ä?Ĺ?Ć?Ć&#x161;Ć?Í&#x2022; Ć&#x2030;Ć?Ç&#x2021;Ä?Ĺ&#x161;Ĺ?Ä&#x201A;Ć&#x161;Ć&#x152;Ĺ?Ć?Ć&#x161;Ć?Í&#x2022; Ć&#x2030;Ć?Ç&#x2021;Ä?Ĺ&#x161;ŽůŽĹ?Ĺ?Ć?Ć&#x161;Ć?Í&#x2022; Ä&#x201A;ĹśÄ&#x161; Ć?Ĺ˝Ä?Ĺ?Ä&#x201A;ĹŻ Ç Ĺ˝Ć&#x152;ĹŹÄ&#x17E;Ć&#x152;Ć?Í&#x2DC; KĆľĆ&#x152; žƾůĆ&#x;Ä&#x161;Ĺ?Ć?Ä?Ĺ?Ć&#x2030;ĹŻĹ?ĹśÄ&#x201A;Ć&#x152;Ç&#x2021; Ĺ&#x161;Ä&#x17E;Ä&#x201A;ĹŻĆ&#x161;Ĺ&#x161; Ć?Ä&#x17E;Ć&#x152;Ç&#x20AC;Ĺ?Ä?Ä&#x17E; Ĺ&#x161;Ä&#x201A;Ć? Ä?Ä&#x17E;Ä&#x17E;Ĺś Ä?ŽŜĆ&#x;ŜƾŽƾĆ?ĹŻÇ&#x2021; Ä&#x201A;Ä?Ä?Ć&#x152;Ä&#x17E;Ä&#x161;Ĺ?Ć&#x161;Ä&#x17E;Ä&#x161; Ä?Ç&#x2021; , Ć?Ĺ?ĹśÄ?Ä&#x17E; ϭϾϳϾÍ&#x2022; Ä&#x201A;ĹśÄ&#x161; Ç Ä&#x201A;Ć? Ć&#x161;Ĺ&#x161;Ä&#x17E; ÄŽĆ&#x152;Ć?Ć&#x161; Ä?ŽůůÄ&#x17E;Ĺ?Ä&#x17E; Ĺ&#x161;Ä&#x17E;Ä&#x201A;ĹŻĆ&#x161;Ĺ&#x161; Ć?Ä&#x17E;Ć&#x152;Ç&#x20AC;Ĺ?Ä?Ä&#x17E; Ć&#x161;Ĺ˝ Ĺ&#x161;Ä&#x201A;Ç&#x20AC;Ä&#x17E; Ä&#x17E;Ä&#x201A;Ć&#x152;ĹśÄ&#x17E;Ä&#x161; Ć&#x161;Ĺ&#x161;Ĺ?Ć? Ä&#x161;Ĺ?Ć?Ć&#x;ĹśÄ?Ć&#x;ŽŜÍ&#x2DC; ĆŠÄ&#x17E;ĹśÄ&#x161;Ĺ?ĹśĹ? Ć&#x161;Ĺ˝ Ĺ˝Ç&#x20AC;Ä&#x17E;Ć&#x152; Ď­ĎŹĎŹÍ&#x2022;ĎŹĎŹĎŹ Ć&#x2030;Ä&#x201A;Ć&#x;Ä&#x17E;ĹśĆ&#x161; Ç&#x20AC;Ĺ?Ć?Ĺ?Ć&#x161;Ć? Ä&#x17E;Ä&#x201A;Ä?Ĺ&#x161; Ç&#x2021;Ä&#x17E;Ä&#x201A;Ć&#x152;Í&#x2022; Ĺ˝Ç&#x2021;ĹśĆ&#x161;ŽŜ ,Ä&#x17E;Ä&#x201A;ĹŻĆ&#x161;Ĺ&#x161; ^Ä&#x17E;Ć&#x152;Ç&#x20AC;Ĺ?Ä?Ä&#x17E; Ć&#x161;Ä&#x201A;ĹŹÄ&#x17E;Ć? Ć&#x2030;Ć&#x152;Ĺ?Ä&#x161;Ä&#x17E; Ĺ?Ĺś ĹľÄ&#x17E;Ä&#x17E;Ć&#x;ĹśĹ? Ć&#x161;Ĺ&#x161;Ä&#x17E; Ĺ&#x161;Ä&#x17E;Ä&#x201A;ĹŻĆ&#x161;Ĺ&#x161; Ä?Ä&#x201A;Ć&#x152;Ä&#x17E; ĹśÄ&#x17E;Ä&#x17E;Ä&#x161;Ć? ŽĨ h ŽĨ D Ć?Ć&#x161;ĆľÄ&#x161;Ä&#x17E;ĹśĆ&#x161;Ć?Í&#x2022; Ć?Ć&#x161;Ä&#x201A;ÄŤÍ&#x2022; Ä&#x201A;ĹśÄ&#x161; ĨÄ&#x201A;Ä?ƾůĆ&#x161;Ç&#x2021; Ç Ĺ?Ć&#x161;Ĺ&#x161; Ä?ŽžĆ&#x2030;Ä&#x201A;Ć?Ć?Ĺ?ŽŜ Ä&#x201A;ĹśÄ&#x161; Ć&#x2030;Ć&#x152;ŽĨÄ&#x17E;Ć?Ć?Ĺ?ŽŜÄ&#x201A;ĹŻĹ?Ć?ĹľÍ&#x2DC;

Gynecologist/Clinical Supervisor Ĺ˝Ç&#x2021;ĹśĆ&#x161;ŽŜ ,Ä&#x17E;Ä&#x201A;ĹŻĆ&#x161;Ĺ&#x161; ^Ä&#x17E;Ć&#x152;Ç&#x20AC;Ĺ?Ä?Ä&#x17E; Ĺ?Ć? Ć?Ä&#x17E;Ä&#x17E;ĹŹĹ?ĹśĹ? Ä&#x201A; 'Ç&#x2021;ĹśÄ&#x17E;Ä?ŽůŽĹ?Ĺ?Ć?Ć&#x161; Ć&#x161;Ĺ˝ Ć?Ä&#x17E;Ć&#x152;Ç&#x20AC;Ä&#x17E; Ä&#x201A;Ć? ĹŻĹ?ĹśĹ?Ä?Ä&#x201A;ĹŻ ^ĆľĆ&#x2030;Ä&#x17E;Ć&#x152;Ç&#x20AC;Ĺ?Ć?Ĺ˝Ć&#x152; ĨŽĆ&#x152; Ć&#x161;Ĺ&#x161;Ä&#x17E; tŽžÄ&#x17E;ĹśÍ&#x203A;Ć? ĹŻĹ?ĹśĹ?Ä?Í&#x2DC; dĹ&#x161;Ä&#x17E; ĹŻĹ?ĹśĹ?Ä?Ä&#x201A;ĹŻ ^ĆľĆ&#x2030;Ä&#x17E;Ć&#x152;Ç&#x20AC;Ĺ?Ć?Ĺ˝Ć&#x152; Ç Ĺ?ĹŻĹŻ Ä&#x17E;ĹśĆ?ĆľĆ&#x152;Ä&#x17E; Ć?Ć&#x161;Ä&#x201A;ÄŤ Ä&#x201A;Ä&#x161;Ĺ&#x161;Ä&#x17E;Ć&#x152;Ä&#x17E;ĹśÄ?Ä&#x17E; Ć&#x161;Ĺ˝ Ć&#x152;Ä&#x17E;ĹŻÄ&#x17E;Ç&#x20AC;Ä&#x201A;ĹśĆ&#x161; Ć&#x152;Ä&#x17E;Ĺ?ƾůÄ&#x201A;Ć&#x;ŽŜĆ?Í&#x2022; Ä&#x201A;Ć?Ć?ĆľĆ&#x152;Ä&#x17E; Ĺ&#x161;Ĺ?Ĺ?Ĺ&#x161;Ä&#x17E;Ć?Ć&#x161; Ć&#x2030;Ć&#x152;ŽĨÄ&#x17E;Ć?Ć?Ĺ?ŽŜÄ&#x201A;ĹŻ Ä&#x201A;ĹśÄ&#x161; Ä&#x17E;Ć&#x161;Ĺ&#x161;Ĺ?Ä?Ä&#x201A;ĹŻ Ć?Ć&#x161;Ä&#x201A;ĹśÄ&#x161;Ä&#x201A;Ć&#x152;Ä&#x161;Ć?Í&#x2022; Ä&#x201A;ĹśÄ&#x161; Ç Ĺ˝Ć&#x152;ĹŹ Ç Ĺ?Ć&#x161;Ĺ&#x161; Ć&#x161;Ĺ&#x161;Ä&#x17E; Ĺ?Ć&#x152;Ä&#x17E;Ä?Ć&#x161;Ĺ˝Ć&#x152; Ä&#x201A;ĹśÄ&#x161; Ĺ&#x161;Ĺ?Ä&#x17E;Ĩ DÄ&#x17E;Ä&#x161;Ĺ?Ä?Ä&#x201A;ĹŻ KĸÄ?Ä&#x17E;Ć&#x152; Ĺ?Ĺś ĨŽĆ&#x152;žƾůÄ&#x201A;Ć&#x;ĹśĹ? ůŽŜĹ? Ć&#x152;Ä&#x201A;ĹśĹ?Ä&#x17E; Ć&#x2030;ĹŻÄ&#x201A;ŜŜĹ?ĹśĹ? Ä&#x201A;ĹśÄ&#x161; Ć&#x2030;ŽůĹ?Ä?Ĺ?Ä&#x17E;Ć?Í&#x2DC;  Ć?ĹľÄ&#x201A;ĹŻĹŻ Ć&#x2030;Ä&#x17E;Ć&#x152;Ä?Ä&#x17E;ĹśĆ&#x161;Ä&#x201A;Ĺ?Ä&#x17E; ŽĨ Ć&#x;ĹľÄ&#x17E; Ç Ĺ?ĹŻĹŻ Ä?Ä&#x17E; Ć?Ć&#x2030;Ä&#x17E;ĹśĆ&#x161; Ć&#x2030;Ć&#x152;Ĺ˝Ç&#x20AC;Ĺ?Ä&#x161;Ĺ?ĹśĹ? Ä?ĹŻĹ?ĹśĹ?Ä?Ä&#x201A;ĹŻ Ä&#x201A;ĹśÄ&#x161; Ć&#x161;Ä&#x17E;Ä&#x201A;Ä?Ĺ&#x161;Ĺ?ĹśĹ? Ć?Ä&#x17E;Ć&#x152;Ç&#x20AC;Ĺ?Ä?Ä&#x17E;Ć? ĨŽĆ&#x152; Ć&#x161;Ĺ&#x161;Ä&#x17E; Ä?Ä&#x201A;Ä&#x161;Ä&#x17E;ĹľĹ?Ä? ,Ä&#x17E;Ä&#x201A;ĹŻĆ&#x161;Ĺ&#x161; Ä&#x17E;ĹśĆ&#x161;Ä&#x17E;Ć&#x152; KÄ?Ͳ'Ç&#x2021;Ĺś Ä&#x17E;Ć&#x2030;Ä&#x201A;Ć&#x152;Ć&#x161;ĹľÄ&#x17E;ĹśĆ&#x161; Ä&#x201A;ĹśÄ&#x161; hĹśĹ?Ç&#x20AC;Ä&#x17E;Ć&#x152;Ć?Ĺ?Ć&#x161;Ç&#x2021; ŽĨ DĹ?ŜŜÄ&#x17E;Ć?Ĺ˝Ć&#x161;Ä&#x201A; WĹ&#x161;Ç&#x2021;Ć?Ĺ?Ä?Ĺ?Ä&#x201A;ĹśĆ?Í&#x2DC; dĹ&#x161;Ĺ?Ć? Ć&#x2030;Ĺ˝Ć?Ĺ?Ć&#x;ŽŜ ŽčÄ&#x17E;Ć&#x152;Ć? Ä&#x201A; Ä?ŽžĆ&#x2030;Ä&#x17E;Ć&#x;Ć&#x;Ç&#x20AC;Ä&#x17E; Ć?Ä&#x201A;ĹŻÄ&#x201A;Ć&#x152;Ç&#x2021; Ä&#x201A;ĹśÄ&#x161; Ä&#x201A; Ĺ?Ä&#x17E;ĹśÄ&#x17E;Ć&#x152;ŽƾĆ? Ä&#x201A;Ä?Ä&#x201A;Ä&#x161;Ä&#x17E;ĹľĹ?Ä? Ć?Ć&#x161;Ä&#x201A;Ć&#x161;ĆľĆ? Ć&#x152;Ä&#x17E;Ć&#x;Ć&#x152;Ä&#x17E;ĹľÄ&#x17E;ĹśĆ&#x161; Ć&#x2030;ĹŻÄ&#x201A;ĹśÍ&#x2DC; WĆ&#x152;ŽĨÄ&#x17E;Ć?Ć?Ĺ?ŽŜÄ&#x201A;ĹŻ ĹŻĹ?Ä&#x201A;Ä?Ĺ?ĹŻĹ?Ć&#x161;Ç&#x2021; Ä?Ĺ˝Ç&#x20AC;Ä&#x17E;Ć&#x152;Ä&#x201A;Ĺ?Ä&#x17E; Ĺ?Ć? Ć&#x2030;Ć&#x152;Ĺ˝Ç&#x20AC;Ĺ?Ä&#x161;Ä&#x17E;Ä&#x161;Í&#x2DC; Ć&#x2030;Ć&#x2030;ĹŻÇ&#x2021; ŽŜͲůĹ?ĹśÄ&#x17E; Ä&#x201A;Ć&#x161; Ĺ&#x161;ĆŠĆ&#x2030;Ć?Í&#x2014;ÍŹÍŹÄ&#x17E;ĹľĆ&#x2030;ĹŻĹ˝Ç&#x2021;ĹľÄ&#x17E;ĹśĆ&#x161;Í&#x2DC; ƾžŜÍ&#x2DC;Ä&#x17E;Ä&#x161;Ćľ Ä&#x201A;ĹśÄ&#x161; Ć&#x152;Ä&#x17E;ĨÄ&#x17E;Ć&#x152;Ä&#x17E;ĹśÄ?Ä&#x17E; Ć&#x152;Ä&#x17E;Ć&#x2039;ĆľĹ?Ć?Ĺ?Ć&#x;ŽŜ ŜƾžÄ?Ä&#x17E;Ć&#x152; 176093Í&#x2DC; dĹ˝ ĹŻÄ&#x17E;Ä&#x201A;Ć&#x152;Ĺś žŽĆ&#x152;Ä&#x17E;Í&#x2022; Ć&#x2030;ĹŻÄ&#x17E;Ä&#x201A;Ć?Ä&#x17E; Ä?ŽŜĆ&#x161;Ä&#x201A;Ä?Ć&#x161; ,Ĺ˝Ć?Ä&#x17E;Ä&#x201A; KĹŠÇ Ä&#x201A;ĹśĹ?Í&#x2022; ,ƾžÄ&#x201A;Ĺś ZÄ&#x17E;Ć?ŽƾĆ&#x152;Ä?Ä&#x17E;Ć? Ĺ?Ć&#x152;Ä&#x17E;Ä?Ć&#x161;Ĺ˝Ć&#x152; ͞ϲϭώͿ ϲώϲͲϭϭϴϰÍ&#x2022; Ĺ&#x161;Ĺ˝ĹŠÇ Ä&#x201A;ĹśĹ?Î&#x203A;Ä?Ĺ&#x161;Ć?Í&#x2DC;ƾžŜÍ&#x2DC;Ä&#x17E;Ä&#x161;ĆľÍ&#x2DC; dĹ&#x161;Ä&#x17E; hĹśĹ?Ç&#x20AC;Ä&#x17E;Ć&#x152;Ć?Ĺ?Ć&#x161;Ç&#x2021; ŽĨ DĹ?ŜŜÄ&#x17E;Ć?Ĺ˝Ć&#x161;Ä&#x201A; Ĺ?Ć? Ä&#x201A;Ĺś Ć&#x2039;ĆľÄ&#x201A;ĹŻ KĆ&#x2030;Ć&#x2030;Ĺ˝Ć&#x152;Ć&#x161;ƾŜĹ?Ć&#x161;Ç&#x2021;Í&#x2022; ĸĆ&#x152;ĹľÄ&#x201A;Ć&#x;Ç&#x20AC;Ä&#x17E; Ä?Ć&#x;ŽŜ Ä&#x161;ĆľÄ?Ä&#x201A;Ć&#x161;Ĺ˝Ć&#x152; Ä&#x201A;ĹśÄ&#x161; ĹľĆ&#x2030;ĹŻĹ˝Ç&#x2021;Ä&#x17E;Ć&#x152;

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MARCH 2012 MINNESOTA PHYSICIAN

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National Commission on Certification of Physician Assistants

PAs from page 34 ties: obtain medical histories, examine and treat patients, order and interpret diagnostic studies, articulate differential diagnoses, and recommend/implement treatment plans for the range of human illnesses and injuries, both acute and chronic. They can perform minor surgery and assist in major surgery, instruct and counsel patients, order or carry out therapy, and prescribe medications. PAs perform those roles within a scope of practice that is established by the supervising physician in accordance with state regulations; generally speaking, PAs can perform any tasks delegated by the physician. “The role of physician assistants is to become the right hand of the physicians they work with,” says Katherine J. Adamson, MA, PA-C, a certified PA for more than 30 years who now serves as a medical consultant to the NCCPA. “The relationship is very collegial, and it is from a team perspective that the physicians are comfortable

The National Commission on Certification of Physician Assistants (NCCPA) is the only certification organization for physician assistants in the United States. Since its inception as a not-for-profit organization in 1975, more than 97,000 physician assistants have been certified by NCCPA. entrusting their patients’ wellbeing to their PA colleagues.” A growing need

The growing need for PAs and other physician extenders is clear. The Association of American Medical Colleges reports that the nation could face a shortage of up to 150,000 physicians in the next 15 years. In addition, America’s senior population is growing at an unprecedented rate, and health care reform could bring millions of additional patients into the system. More and more practices will begin to rely on the breadth of knowledge and skills that certified PAs provide to meet this growing demand. “With the growing strain on the health care system, the demand for physician assistants has never been higher, and it

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MINNESOTA PHYSICIAN MARCH 2012

will continue to grow,” says Randy D. Danielsen, PhD, PA-C, senior vice president of the NCCPA Foundation and emeritus professor and former dean of the Arizona School of Health Sciences at A.T. Still University. “In my 38 years as a certified PA and a longtime educator, I have yet to see the demand for the profession met. It’s incredible to watch the profession try to keep up.” According to the Accreditation Review Commission on Physician Assistant Education (ARC-PA), the profession’s accreditation authority, the number of accredited PA programs increased from 54 in 1991 to 159 in 2011. ARC-PA’s executive director, John McCarty, reports that there are more than 50 new programs in the process of seeking accreditation that could potentially be accredited by the end of 2015. Over the past decade, PA practice has steadily trended toward specialization, with today’s PAs practicing in virtu-ally every medical and surgical specialty. According to an annual census report by the American Academy of Physician Assistants, in 2000, approximately 51 percent of PAs worked in primary care, with the remainder practicing in a range of specialties. By 2010, only 31 percent remained in primary care. “PAs are going to go where the doctors go, just given the nature of our profession,” says Adamson. “We pride ourselves as a profession on our solid grounding in primary care, which we demonstrate every time we take and pass our national recertification exam.” Danielsen notes that “because PAs are trained as generalists and have to maintain a generalist fund of knowledge to maintain certification, we often are able to bring a broader range of care even within specialty practice.”

In recognition of this trend toward specialization, the NCCPA launched the Certificate of Added Qualifications (CAQ) program in 2011 as a complement to the existing certification process. The CAQ program provides a way for certified PAs to document specialty experience, skills, and knowledge. The program includes licensure, CME, and experience requirements as well as a specialty exam. Today it is available to certified physician assistants practicing in cardiovascular and thoracic surgery, emergency medicine, nephrology, orthopedic surgery, and psychiatry. According to a survey conducted by the Bantam Group in 2011, 66 percent of physicians agree that a CAQ is a valuable credential for certified PAs. An expanding role in patient care

With health care reform and the inevitable changes in the American health care system, certified PAs will undoubtedly play a larger role in providing care for current patients, as well as for the millions of new patients expected to enter the system. Most physician organizations, including the American Medical Association, support physician-led health care teams that include physician assistants. In fact, the American Academy of Family Physicians issued a joint policy statement with the American Academy of Physician Assistants in February 2011, calling for health policies that recognize physician assistants as primary care clinicians in multidisciplinary, physiciandirected teams. For additional information on certified physician assistants and the CAQ program, visit www.nccpa.net. Pamela M. Dean, MBA, is vice president of operations with the National Commission on Certification of Physician Assistants.


NEW POSITIONS:

Family Practice Urgent Care Dynamic, independent 3 location, single-specialty practice in northwest Minneapolis suburbs is seeking additional associates for its Rogers site and has Full Time/ Part Time shifts in the Crystal and Rogers Urgent Care. • • • • •

Partnership opportunity after 2 years Competitive salary with incentives Excellent benefits, 401k/employer paid pension Practice at one site/one hospital Physician-owned

Please contact or fax CV to: Joel Sagedahl, M.D. 1495 Highway 101 North, Plymouth, MN 55447 763-504-6600 • Fax 763-504-6622

The Northwest Wisconsin Region of Mayo Clinic Health System has more than 300 physicians representing a wide range of medical specialties in a community healthcare setting. We are a respected and financially secure organization with strong emphasis on high quality care and patient satisfaction. A Mayo One emergency medical helicopter is based in Eau Claire, offering surrounding communities access to the area’s only verified Level II trauma center. Our current opportunities include: Dermatology Oncology Emergency Medicine Orthopedic Surgery – General, Sports, & Trauma Endocrinology Palliative Care Family Medicine Pathology General Surgery PM & R Hospitalist Psychiatry – Adult Internal Medicine Rheumatology Neurology Urology Neurosurgery If you wish to learn more or to express interest in this position, please contact: Cyndi Edwards/Christie Blink by phone (800-573-2580); email edwards.cyndi@mayo.edu or blink.christie@mayo.edu

Visit our website at www.NWFPC.com

Delivering care that makes patients feel known and understood At Essentia Health, we have a supportive group of 750 physicians across 55 medical specialties. Located in large and small communities across Minnesota, Wisconsin, North Dakota and Idaho, Essentia Health is emerging as a leader in high-quality, cost-effective, patient-centered care. EOE/AA

LEARN MORE

EssentiaHealth.org/Careers 800.342.1388 ext 63165

MARCH 2012 MINNESOTA PHYSICIAN

37


Prostate from page 17 USPSTF is averse to any screening whatsoever. PSA screening does detect prostate cancer at earlier stages, when men have more options and success with treatment. The prostate cancer mortality rate has dropped in the post-PSA era; and while there are disparate conclusions on the death rate benefits from screening, studies appear to show some survival benefit, which accrues over time. However, it is also clear that screening can lead to significant overdiagnosis and subsequent overtreatment, with side effects and costs being important factors. Given these complexities, how can primary care physicians in their everyday practice best serve their patients regarding PSA screening? As noted, virtually all guidelines recommend a shared decision-making model for PSA testing—discussing the harms and benefits and individualizing the discussion by considering the patient’s anticipated lifespan, preferences, and values while

PSA screening does detect prostate cancer at earlier stages, when men have more options and success with treatment. acknowledging the variability in PSA results and in the guidelines. Achieving this without some guidance during a routine clinic appointment would appear to be a stupendous task. It may help primary care doctors advocate for their patients to use a prostate cancer decision aid (available from the Centers for Disease Control and Prevention at www.cdc.gov/ cancer/prostate/pdf/prosguide .pdf) and to focus on the following key points culled from the guidelines: • Shared decision-making regarding PSA testing is in the patient’s best interest. Potential benefits and overdiagnosis need to be part of the discussion. • Prostate cancer screening should include history (voiding symptoms, bone pain), DRE,

and PSA. Symptomatic men should be screened. • Informed asymptomatic men should be offered the yearly test at age 40 or 50. Consider early testing for blacks, and those with a close family member who has been diagnosed with prostate cancer. • Interpretation of the PSA by the screening physician is critical, as there is a continuum of risk. The PSA threshold of 4.0 ng/dl by itself is no longer valid. The decision for urology referral and possible biopsy may now account for many risk factors (DRE, age, family history, ethnicity, symptoms, PSA velocity, etc.). • Asymptomatic men with a lifespan of less than 10 years probably will not benefit from screening.

• While there are new prostate cancer biomarkers, they are unproven. PSA remains the best test available. As of the end of January 2012, the USPSTF's statement was still in draft form, and it may yet be modified. Whatever the outcome, primary care physicians are encouraged to remain educated and openminded about PSA screening data and guidelines, advocating for men to help them make informed prostate cancer screening decisions. Decision aids can help make this discussion more efficient. We urologists, who are in the unique position of diagnosing and treating prostate cancer, need to take a strong leadership role as the paradigm shift “unlinking” diagnosis and immediate aggressive treatment evolves. Thomas J. Stormont, MD, is a urologist with Stillwater Medical Group.

continuing medical education 30th Annual OB/GYN Update

April 12-13, 2012

Psychiatry Update for Primary Care

April 19-20, 2012

• Child and Adolescent Mental Health • Adult Mental Health

Pediatric Fundamental Critical Care Support

April 19, 2012 April 20, 2012

May 3-4 and November 8-9, 2012

Fundamental Critical Care Support 30th Annual Strategies in Primary Care Medicine Midwestern Region Burn Conference

July 19 -20, 2012 September 20-21, 2012 October 11-12, 2012

• Pre-Conference Workshops – Burn Rehabilitation: The Bridge to Recovery – The Pathway to Improving Outcomes for Pediatric Burn Injuries (includes simulation-based learning) • Post-Conference ABLS Provider Course

Optimizing Mechanical Ventilation 13th Annual Women’s Health Conference

education that measurably improves patient care 38

MINNESOTA PHYSICIAN MARCH 2012

October 10, 2012

October 13, 2012

October 26-28, 2012 November 2, 2012

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You wouldnâ&#x20AC;&#x2122;t give a 2-year-old a drink, so why would you give one to an unborn child? As a physician, itâ&#x20AC;&#x2122;s your responsibility to let her know: the U.S. Surgeon General Advisory says no amount of alcohol is safe during pregnancy. Share 049: Zero Alcohol For Nine Months.

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We protect your peace of mind. And we do it in lots of ways for physicians, facilities and hospitals. Whatever your situation, we’ve been there, and will be there. We’ve gotten good at it. Excellent, actually, with a proven success rate. It’s a peace of mind movement. And we’d love to have you along. Join the Peace of Mind Movement at PeaceofMindMovement.com,or contact your independent agent or broker.

Minnesota Physician March 2012  

Health care infomation for Minnesota doctors Cover: Medical care and health care by E. John English, MD Stepping up patient safety by Karyn...

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